Mesquite Village Wellness & Rehabilitation

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that the residents' environment remained free of hazards as was possible for three of eight Residents (Resident #2, #3 and #4) reviewed for accident hazard. The facility failed to ensure that Resident #4 did not have a container of disinfectant wipes on his bedside table on 07/08/26. The facility failed to ensure that Resident #2 did not have a container of Clorox disinfectant wipes, Fantastik Disinfectant multipurpose cleaner spray, and a bottle of Fabuloso cleaning liquid on his bedside table on 07/08/26. The facility failed to ensure that Resident #3 did not have Lysol air sanitizer aerosol can and a bottle of nail polish remover on her bedside table 07/08/26. These deficient practices placed the residents at risk for accidental injury, misuse and, exposure to hazardous chemicals.

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, the comprehensive person-centered care plan, and the residents' goals and preferences for one of eight residents (Resident #5) reviewed for respiratory care. The facility failed to ensure Resident #5's oxygen nasal canula and BIPAP mask were properly stored on 07/08/26. These failures could place residents at risk of respiratory infection, respiratory complications, and not having their respiratory needs met. Findings Include 1. Record review of Resident #5's face sheet, dated 07/08/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with the following: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for two of eight residents (Residents #4, and #3) reviewed for medication storage. 1. The facility failed to ensure Resident #4's Trimicolone ointment 0.5% was not on top of the resident's side table on 07/08/26. 2. The facility failed to ensure Resident #3's melatonin gummies, melatonin tablets and Asper cream lidocaine cream were not on her bedside table on 07/08/26 These failures could place residents at risk of misuse of medications and possible adverse reactions.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement Federal, State, and local laws and regulations regarding smoking, smoking areas, and smoking safety and their own smoking policy for one (Resident #1) of 8 residents reviewed for smoking and compliance. The facility failed to implement their smoking policy regarding Resident #1's noncompliance with smoking on 07/08/26. Resident #1 had smoking paraphernalia in his possession. This failure could affect residents' safety by smoking in other areas than the designated area which could lead to an unsafe smoking environment.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for five of fifteen resident rooms (room [ROOM NUMBER], #2, #3, #4, and #5) on Hall 4, and two of three shower rooms observed for cleanliness. The facility failed to ensure Resident room [ROOM NUMBER], #2, #3, #4, and #5 on Hall 4 were thoroughly cleaned and sanitized. The facility failed to ensure the shower room on Hall 4 and the shower room near the nurses' station was thoroughly cleaned and sanitized. These deficient practices could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for two of seven residents (Resident #1, Resident #2) reviewed for abuse, neglect, and exploitation. The facility failed to ensure Resident #2 was free from abuse by Resident #1. This failure could place residents at risk for abuse or neglect that could lead to serious harm.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure the Comprehensive Care plan was reviewed and revised after each assessment, including both the comprehensive and quarterly review assessments for one (Resident #1) of 12 residents reviewed for Care plans. The facility failed to ensure their IDT or MDS [BH1] Coordinator added Resident #1's ICD Code L89.300 Pressure injury of buttock, unstageable diagnosis to his care plan when on 01/31/24, he was diagnosed with an unstageable pressure injury of buttock and prior to his discharge on [DATE]. This failure could affect all residents by placing them at risk of not having a complete profile which could result in inadequate care and result in a decrease in health and psycho-social well-being.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure the residents received care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the resident's clinical condition demonstrated that they were unavoidable for one (Resident #1) of 12 residents reviewed for Wound care services. The facility failed to ensure Resident #1 was free from pressure injuries and on 01/31/24 he developed a pressure injury of buttock, unstageable and wound care treatments were started. Subsequently, on 09/27/24 Resident #1's Dr./NP ordered for him to get a wound care consult because he had an open sacral wound, however it was not completed because ADON G said he did not have a wound. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to ensure they provided care included but was not limited to assessing, evaluating, planning and implementing resident care plan and responding to resident's needs for one (Resident #1) of 12 residents reviewed for Nursing services. 1. The facility failed to ensure ADON G referred Resident #1 to the Wound care Doctor after he was diagnosed with an open sacral wound on 09/27[BH1] [BH2] /24 and prior to discharge on [DATE]. 2. The facility failed when ADON G stated she was aware of the Physician's order dated 09/27/24 for a wound care consult for Resident #1 but felt he did not have a wound on his buttock so she did not follow the Doctor's order from 09/27/24 to 12/19/24. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to ensure they provided 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 one (Resident #1) of 12 residents reviewed for Pharmacy services. The facility failed to ensure LVN H and LVN X gave Resident #1 his Ammonium Lactate ointment on his lower legs as prescribed by his doctor on [DATE], [DATE], [DATE], [DATE] and [DATE][BH1] prior to discharge on [DATE]; Subsequently, the nurses stated it was unavailable with no documentation as to why. This failure could affect all residents by placing them at risk of going without their medications which could cause a resident to have a decline in health and psycho-social well-being.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for one (Resident #1) of 12 residents reviewed for Medical records. The facility failed to ensure the IDT or MDS Coordinator added Resident #1's Pressure Injury on buttocks, unstageable diagnosis to his EMR profile, after he was [BH1] diagnosed on [DATE] with it and prior to his discharge on [DATE]. This failure could affect all residents by placing them at risk of getting missed care and treatments if no one were aware of their diagnosis, which could lead to decreased health and psycho-social well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents' 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 3 (Residents #10, #12, and #36) of 4 residents reviewed for call lights.1. The facility failed to ensure Resident #10 had their call light within reach while resident was in their wheelchair.2. The facility failed to ensure Resident #12 had their call light within reach while in their bed.3. The facility failed to ensure Resident #36 had their call light within reach while in their bed. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that residents had suitable, nourishing meals and snacks outside of scheduled meal service time for 1 of 1 facility reviewed. -The facility failed to ensure snacks were prepared, provided, and offered to residents after breakfast, lunch, and dinner. This failure could affect all residents who received meals served from the facility's only kitchen by placing residents at risk for, unplanned weight loss, and side effects from medication given without food, and diminished quality of life. Findings Included:In a confidential group meeting on 08/06/2025 at 10:05am 6 out of 14 residents stated the facility did not offer or pass out snacks after each mealtime. 6 out of 14 residents stated the facility stopped offering and passing out snacks about three months ago. [...]

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 the facility's only kitchen reviewed for food safety.1. The facility failed to ensure food items in the freezer were labeled with the item description (handwritten or manufacturer's label), had the received by date, the opened date and/or the consume by or expiration by dates.2. The facility failed to ensure food items in the dining room were labeled with the item description (handwritten or manufacturer's label), had the received by date, the opened date and/or the consume by or expiration by dates.3. The facility failed to ensure dietary staff wore proper hairnets while working in the kitchen. These failures could place residents at risk for food-borne illness and cross contamination. Findings Include: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program for 1 of 1 facility reviewed for pests in that: Gnats were observed in multiple areas of the facility: Hall100, Hall 400, and Hall 500. This failure could affect residents by placing them at an increased risk of exposure to pests and vector-borne diseases and infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Nutrional supplements were given as the physician had ordered to meet the Nutrional needs of two residents (Resident #21 and #26) of five residents observed. 1. MA B administered Resident #21's Med pass 2.0 (nutritional supplement) without measuring the correct amount. The physician order read to administer 60 ml (2 ounces); the MA administered 4 ounces. 2. MA B administered Resident #26's Med Pass 2.0 (nutritional supplement) without measuring the correct amount. The physician order read to administer 90 ml 93 ounces); the MA administered 4 ounces. These failures could affect the residents, by placing them at risk for not receiving their therapeutic dosage medications as ordered by the physician and decreased healthFindings included: Observation on 08/05/2025 at 3:27 p.m. [...]

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 three (Resident #20, #31 and #35) of five residents observed for infection control in that: MA B failed to disinfect the blood pressure cuff (to measure the blood pressure) in between vital sign checks for Resident #20, and Resident #31. CNA D failed to change their soiled gloves and wash hands during incontinent care to Resident #35. This failure could place residents at risk for spread of infection through cross-contamination.

Inspectors wroteBased on interview and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive assessment and quarterly review assessments for one (Resident #1) of four residents were reviewed for comprehensive care plans. The facility failed to review and revise Resident #1's care plan quarterly and after each assessment. This failure could affect residents by placing them at risk for not having their individual needs met.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate supervision to prevent accidents for 1 (Resident #1) of 3 residents reviewed for elopement risk. On 05/08/24 around 2:00 PM, Resident #1 was found ¼ of a mile from the facility walking on the sidewalk of a two-lane road going into a residential area, after he had eloped from the facility while wearing a wander guard and at the facility for respite care. The non-compliance was identified as PNC. The IJ began on 05/08/24 and ended on 05/10/24. The facility had corrected the non-compliance before the survey began. This failure could place residents who used wander guard at risk for serious injuries.

Inspectors wroteBased on interviews, and record reviews, the facility failed to obtain from hospice the most recent hospice plan of care specific to each patient needs for 1 of 3 residents (Resident #59) reviewed for hospice services. The facility failed to ensure Resident #1' s hospice care was care planned. This failure could place residents at risk of needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the transfer or discharge was documented in the resident's medical record and appropriate information was communicated to the receiving health care institution or provider for one (Resident #1) of 4 residents reviewed for facility-initiated discharges. The facility failed to provide documentation for an immediate facility-initiated discharge for Resident #1 that the resident's needs could not be met and attempted to meet the resident's needs. The failure could affect residents by placing them at risk of not having access to adequate care in a nursing home facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable and homelike environment for seven (Resident #2, #10,#15, #23, #44, #99 and #100) of 34 residents observed for wheelchairs, in that: The facility failed to properly maintain wheelchairs for Residents #2, #10, #15. #23, #44, #99 and #100. The wheelchair arm rest pads were torn and cracked with exposed interior foam. The arm rest pads could not appropriatley be cleaned due to the cracked and exposed foam. There was posed a safty problem as the cracked arm rest pads could cause injury to the resdients. These failures could place residents at risk for diminished quality of life and at risk for skin issues and discomfort due to the lack of a well-kept wheelchairs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for three residents (Residents #17, #38 and #148) of thirteen residents reviewed for palatable food. The facility failed to provide palatable food served at an appetizing temperature to residents who complained the food was cold or not hot during breakfast on 5/1/23 and 5/2/23. This failure could place residents who ate food from the kitchen at risk for weight loss, altered nutritional status and diminished quality of life.

Inspectors wroteBased on observations, interviews and record review the facility failed to store, distribute, and serve food in accordance with professional standards for food safety in the facilities only kitchen. The facility failed to ensure food items past their expiration date were discarded. The facility failed to ensure different types of thawing meats were kept separate to reduce the risk of cross contamination. These failures could place residents at risk for food-borne illness.

Inspectors wroteBased on interview and record review the facility failed to review and revise the person-centered care plan to reflect the current condition for 2 (Residents #8 and #27) of 6 residents reviewed for care plan revisions. The facility failed to ensure Resident #8's care plan was updated to reflect her desire for positioning while eating and taking medications. The facility failed to ensure Resident #27's care plan was updated to reflect his refusal for treatment concerning his diabetic ulcers on his feet. This deficient practice could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for one (400 Hall) of two halls reviewed for environment. The facility failed to ensure windows, furniture, beds, were in good repair for Rooms #411, #409, #405, #408, and the nurse's station. This failure could affect residents and the staff by placing them at risk for diminished quality of life due to the lack of a well-kept environment.