Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Christian Care Communities And Services Mesquite during CMS and state inspections, most recent first.
A resident with multiple medical conditions did not receive a requested longer bed in a timely manner despite repeated requests from family and staff approval. The bed was delivered but placed on the wrong side, and the resident was not accommodated until the issue was raised again in a care plan meeting, resulting in unmet needs and preferences.
Staff failed to keep medication carts locked and secure, leaving them unattended and accessible to unauthorized individuals. On two occasions, a medication aide and an LVN left their carts unlocked while administering medications or assisting residents elsewhere, with one resident approaching an unattended cart. Both staff members acknowledged knowing the policy but did not follow it, and the carts contained various prescription medications.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, resulting in an unsafe environment for residents.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A resident with severe cognitive impairment and a history of fractures, who required a two-person assist for transfers, was transferred by a medication aide using a sit-to-stand lift without a second staff member present. The aide did not notify the nurse when the resident complained of pain before the transfer, and the resident was later found to have an acute spiral femur fracture. Staff interviews and records confirmed that facility policy required two staff for all mechanical lift transfers and immediate nurse notification for pain complaints prior to care.
Expired syringes were found stored in a medication room, with staff interviews revealing uncertainty about responsibility for monitoring expiration dates and the risks of using expired supplies. The DON and Central Supply both indicated shared responsibility, but neither identified the expired items during routine checks. No policy specific to expiration dates for supplies was provided upon request.
Surveyors found that molded fruit was not removed from refrigeration and dented cans were not separated in dry storage, contrary to facility policy. Staff interviews confirmed inconsistent practices in sorting and inspecting food items, and the Dietary Manager acknowledged that these lapses could lead to contamination. Facility policy requires inspection and proper storage of food items, but these procedures were not consistently followed.
The facility failed to ensure the ADON maintained a valid nursing license, resulting in the ADON working with an expired license. The HR Manager discovered the lapse during a routine check, leading to the ADON's removal and termination. The facility's previous system relied on staff to track their own licenses, which contributed to the oversight.
A resident with atrial fibrillation did not receive Eliquis for a month due to a transcription error in the EHR after hospital discharge. The error was discovered after the resident was hospitalized with limb ischemia, leading to an amputation. The facility's admission process failed to ensure proper medication reconciliation.
A resident did not receive the anticoagulant Eliquis for a month due to a failure in transcribing hospital discharge orders into the EHR. The oversight was not caught by the facility's checks, leading to the resident being at risk for thrombotic events, which resulted in a hospital admission and subsequent amputation.
A facility failed to report an alleged abuse incident involving a resident and a physical therapist to state authorities. The resident's family claimed the therapist caused bruising by tightening a gait belt, but the resident did not express fear or claim intentional harm. The DON did not report the incident as the resident denied abuse, despite facility policy requiring such reports.
The facility failed to maintain safe wheelchairs for five residents, leading to cracked armrests with exposed foam. Staff did not consistently report or address the issues, and there was no log to track repairs.
The facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards. Observations revealed multiple instances of improperly labeled and dated food items in the refrigerator and freezer, including expired items and undated prepared meals. Interviews with dietary staff confirmed lapses in labeling and disposal practices, attributing some issues to the type of markers and labels used.
Failure to Provide Timely Bed Accommodation for Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide reasonable accommodation for a resident's needs and preferences regarding bed size. The resident, an elderly male with multiple diagnoses including encephalopathy, type 2 diabetes mellitus, vascular dementia, depressive disorder, cataract, atherosclerotic heart disease, heart failure, unsteadiness, and reduced mobility, required a longer bed due to his height, as his feet were pressing against the footboard of the standard bed. The resident's family made multiple requests for a longer bed: first verbally, then via email, and again during a care plan meeting. Despite these requests, the resident was not provided with the longer bed in a timely manner. Staff interviews and record reviews revealed that although the request for a longer bed was approved by the administrator and a bed was delivered to the room, it was placed on the wrong side and not assigned to the resident. The breakdown in communication and follow-through resulted in the resident not receiving the necessary accommodation until after the issue was raised again in a care plan meeting. The facility's failure to ensure the completion of the task led to the resident not having his needs and preferences met as required by resident rights policies.
Medication Carts Left Unlocked and Unattended by Staff
Penalty
Summary
Facility staff failed to ensure that medication carts were kept locked and secure, as required by facility policy and professional standards. On two separate occasions, a medication aide and an LVN left their respective medication carts unlocked and unattended while administering medications or attending to residents in other rooms. Observations confirmed that the locks on both carts were disengaged, with visible indicators showing the carts were unlocked. In one instance, a resident in a wheelchair approached the unattended cart, seeking pain medication, while the medication aide was in another room. The aide acknowledged awareness of the requirement to keep the cart locked but admitted to forgetting and leaving it open. In the other instance, the LVN left syringes and vials of unknown medication on top of the unlocked cart and stated that she routinely left the cart unlocked during medication passes for convenience, despite knowing the policy. Review of the medication carts revealed that they contained various prescription medications for residents, including drugs for depression, high blood pressure, thyroid issues, seizures, and nausea. Both staff members interviewed recognized that leaving the carts unlocked could allow unauthorized access to medications. The interim ADON confirmed that it was the expectation for medication carts to be locked when not in use and that staff using the carts were responsible for ensuring their security. Facility policy also required that medication carts be locked at all times when out of the nurse's view.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential resident information or proper record-keeping were not followed as expected. No additional details regarding specific residents, staff actions, or the circumstances leading to the deficiency are provided in the report.
Failure to Provide Adequate Supervision and Safe Transfer Practices
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, a history of multiple fractures, osteoporosis, and total dependence on staff for mobility and self-care was not provided adequate supervision and assistive devices to prevent accidents. The resident's care plan required a two-person assist for transfers using a sit-to-stand mechanical lift. On the day of the incident, a medication aide (MA) who was filling in for the usual CNA performed a transfer using the sit-to-stand lift without a second staff member present, contrary to facility policy and the resident's care plan. During the transfer, the resident complained of pain, but the MA did not notify the nurse before proceeding with the transfer. The nurse was only informed of the pain after the transfer was completed. Subsequent assessment and imaging revealed the resident had sustained an acute spiral fracture of the left femur. Interviews with staff confirmed that mechanical lift transfers were to be performed with two staff members and that any complaints of pain prior to care required immediate nurse notification for assessment. The facility's policy on mechanical lifts explicitly required two staff for all transfers and an assessment of the resident's condition before use. The MA acknowledged being aware of these requirements but proceeded alone due to lack of available assistance. The nurse and other staff confirmed that the resident was dependent for all mobility and that no incidents or changes in condition were reported prior to the injury. The event was identified as past non-compliance, with the Immediate Jeopardy period beginning and ending before the state's investigation.
Expired Medication Administration Supplies Not Removed from Medication Room
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring that expired medication administration supplies were removed from the 2100 hall medication room. During an observation, expired syringes were found on the shelves, including a 100-count box of 5mL 22-gauge x 1.5-inch syringes and a 100-count box of 3mL 23-gauge x 1-inch syringes, both past their expiration dates. RN A confirmed the syringes were expired and acknowledged the risk of infection if used, but stated she had not used any of them. Central Supply, responsible for delivering and rotating supplies weekly, indicated that he only checked expiration dates when restocking and believed that nursing management shared responsibility for monitoring expiration dates. He was unsure if expired supplies could cause harm to residents. The DON reported conducting weekly audits of the medication rooms but did not notice the expired syringes and stated that both she and the Unit Manager would be responsible for monitoring once a plan of correction was completed. The DON was also unsure of the risks associated with using expired supplies but expected that no expired items would be present. When policies regarding expiration dates for supplies were requested from administration, none were provided by the time of exit. The facility's policy on medication storage indicated that nursing staff are responsible for maintaining medication storage areas in a clean, safe, and sanitary manner, and that outdated drugs or biologicals should be returned or destroyed.
Failure to Remove Molded Fruit and Separate Dented Cans in Food Storage
Penalty
Summary
Surveyors observed that the facility failed to adhere to professional standards for food storage and safety in the kitchen. During an inspection of the walk-in refrigerator, multiple containers of fruit, including grapes, strawberries, and raspberries, were found to be visibly molded. In the dry storage area, dented cans of cream of chicken and tapioca pudding were found stored with other canned goods, rather than being separated as required by facility policy. Interviews with staff revealed that responsibilities for sorting and inspecting food items were not consistently followed. One staff member stated that although sorting through canned goods and fruits was not her primary responsibility, she had performed these tasks in the past and was aware that dented cans should be separated to prevent infection. The Dietary Manager confirmed that dented cans are supposed to be stored separately and returned to the vendor, and that molded fruit should be refused or discarded. Review of the facility's policy indicated that food should be inspected for quality and safety upon delivery, but these procedures were not consistently implemented.
Expired Nursing License Overlooked for ADON
Penalty
Summary
The facility failed to ensure that the Assistant Director of Nursing (ADON) maintained a valid nursing license, as required by state laws. The ADON's nursing license had expired, and this lapse was not identified by the facility's existing processes for monitoring staff qualifications. The Human Resources (HR) Manager stated that the responsibility for verifying licenses was initially shared among different staff members, which led to the oversight. The HR Manager discovered the expired license during a routine check and informed the Administrator and Director of Nursing (DON), leading to the ADON being removed from the floor and subsequently terminated. Interviews with the HR Manager, Administrator, and DON revealed that the facility's previous system relied on individual staff members to keep track of their own license expirations. This system failed in the case of the ADON, who continued to work with an expired license. The HR Manager and DON have since taken on the responsibility of monitoring licenses, but at the time of the incident, the lack of a centralized tracking system contributed to the oversight. The facility conducted an audit to ensure no other licenses were expired, and no additional issues were found.
Failure to Administer Anticoagulant Medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of Eliquis, an anticoagulant medication. The resident, a female with a history of atrial fibrillation and a recent hip fracture, was not administered Eliquis as ordered from August 26, 2024, to September 26, 2024. This lapse occurred after the resident was discharged from the hospital with orders to continue Eliquis, but the medication was not transcribed into the electronic health record (EHR) by the nursing staff. The deficiency was identified when the resident was admitted to the hospital on September 26, 2024, with non-salvageable limb ischemia, leading to a mechanical thrombectomy and subsequent above-knee amputation. Interviews with facility staff revealed that the medication error was due to a failure in the transcription process. The Licensed Vocational Nurse (LVN) responsible for transcribing the discharge orders believed she had entered the Eliquis order into the EHR but was unaware of the omission until later. The Director of Nursing (DON) was informed of the error by a hospital case worker on October 18, 2024. The facility's admission process at the time relied on the floor nurse to review and transcribe medications with the physician, but the backup checks failed, as the admission nurse was not working on the day of the resident's return from the hospital. The facility's policy required the interdisciplinary team to evaluate medication usage to prevent and detect medication-related problems, but this process was not effectively implemented in this case.
Removal Plan
- The admission checklist was updated and required the floor nurse, nurse manager, and the DON to review medications on all new admissions.
- The DON was responsible for monitoring the admission checklist and ensuring the medications were transcribed.
- The facility reviewed all new admissions during meetings, and the ADM monitored the admission checklist to ensure it was completed during meetings.
- A medication reconciliation competency was completed for every nurse.
- Implemented a new protocol with three checks for medication reconciliation: floor nurse, unit manager, and DON.
- Training provided for medication orders and the admission process.
- The medication list would be sent to the pharmacy to be reviewed for accuracy.
Failure to Transcribe and Administer Anticoagulant Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, specifically in the accurate transcription and administration of the medication Eliquis, an anticoagulant. The resident, who had been admitted with diagnoses including atrial fibrillation and a fractured left hip, was discharged from the hospital with orders to continue Eliquis. However, the facility did not transcribe or administer the medication from the time of the resident's return from the hospital until a month later. The deficiency was identified when it was discovered that the resident's hospital discharge orders for Eliquis were not entered into the electronic health record (EHR) by the nurse responsible for transcribing the orders. The nurse believed she had entered the order, but it was missing from the resident's medication administration record (MAR). This oversight was not caught by the facility's existing checks, leading to the resident not receiving the prescribed medication for an extended period. The failure to administer Eliquis as ordered resulted in the resident being at risk for thrombotic events, which was confirmed when the resident was later admitted to the hospital with a blood clot that led to a left above-the-knee amputation. Interviews with facility staff revealed that the medication reconciliation process was not adequately followed, and the necessary checks to ensure accurate transcription of medication orders were not effectively implemented.
Removal Plan
- The admission checklist was updated and required the floor nurse, nurse manager, and the DON to review medications on all new admissions.
- The DON was made responsible for monitoring the admission checklist and ensuring the medications were transcribed.
- The facility reviewed all new admissions during meetings, and the ADM monitored the admission checklist to ensure it was completed.
- A new admission checklist was implemented with sections for the floor nurse, unit manager, and DON to sign once medications were reviewed and entered into the EHR.
- The admission process was updated to include additional checks by the unit manager and DON to ensure medications were transcribed accurately.
- The floor nurse was made responsible for reconciling the medications with the doctor, then the unit manager would verify the medications were accurately transcribed, and the DON would review the medications again.
- The medication list would be sent to the pharmacy to be reviewed for accuracy.
- A medication reconciliation competency was completed for every nurse.
- A new protocol was implemented with three checks for the medication reconciliation: the floor nurse, the unit manager, and the DON.
- Training for medication orders and the admission process was provided to the nursing staff.
- The pharmacy consultant was included in the medication checking process.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to immediately report an allegation of abuse to the Health and Human Services Commission (HHSC) for one resident. The incident involved a resident who was alleged to have been intentionally injured by a physical therapist (PT B) during a therapy session. The resident's family member reported the incident to the facility, claiming that PT B had caused severe bruising by tightening a gait belt around the resident. Despite the allegation, the facility did not report the incident to the state authorities as required. The resident, who was cognitively intact and able to express herself, reported that PT B had tightened the gait belt too much, which she believed caused the bruise. However, she did not express fear or claim intentional harm, and she suggested that PT B needed further training. The resident was on anticoagulant therapy, which could have contributed to the bruising. Interviews with staff members, including PT B and a witness, PT C, did not corroborate the family member's allegation of intentional harm. The attending physician noted that the bruising could have been caused by routine care or other factors, such as the resident's obesity and use of blood thinners. The Director of Nursing (DON) was informed of the allegation but did not report it to the state, as the resident denied any abuse. The facility's policy required reporting all allegations of abuse, but the DON and the Administrator (ADM) believed that if the resident did not use the term "abuse," it was not necessary to report. The facility conducted an internal investigation, including interviews and staff training, but the failure to report the allegation to the state was identified as a deficiency.
Failure to Maintain Safe Wheelchairs
Penalty
Summary
The facility failed to ensure that all assistive devices, specifically wheelchairs, were maintained and free of hazards for five residents. Observations revealed that the wheelchairs of Residents #10, #12, #53, #69, and #183 had cracked armrests with exposed foam, which could potentially cause injury. Despite the residents being dependent on wheelchairs for mobility, the necessary repairs were not made in a timely manner, and the issues were not properly reported or addressed by the staff. Resident #10, a severely cognitively impaired female with dementia and heart failure, was observed sitting in a wheelchair with cracked armrests. Similarly, Resident #12, who has moderate cognitive impairment and diabetes, reported that her wheelchair's armrests were loose, but she could not recall when she informed the charge nurse. Resident #69, also with dementia and muscle weakness, was found in a wheelchair with cracked armrests. Resident #53, a male with dementia and lack of coordination, had a wheelchair with similar issues. Lastly, Resident #183, a new admit with dementia and mobility issues, was observed in a wheelchair with cracked armrests. Interviews with staff revealed a lack of communication and follow-up regarding the maintenance of wheelchairs. CNA B and LVN C stated that they were supposed to report wheelchair issues to the therapy department, but this was not consistently done. The Director of Rehabilitation confirmed that the therapy department was responsible for repairs but was unaware of the issues with the wheelchairs on the memory care unit. There was no log or repair communication book to track reported issues, leading to delays in addressing the problems.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Observations revealed multiple instances of improperly labeled and dated food items in the facility's refrigerator and freezer. Specifically, peeled potatoes, a brown liquid substance, and an opened salad mix were found without dates. Additionally, expired items such as limes, tortilla shells, and a bag of liquid egg mix were discovered. In the freezer, undated chicken wings, cauliflower, and cooked plates of puree were noted. These deficiencies were confirmed through interviews with the Dietary Supervisor, Puree Cook A, and the Dietary Manager, who acknowledged the lapses in labeling and disposal practices, attributing some issues to the type of markers and labels used, especially in the freezer where labels tend to fall off. The Dietary Supervisor and Dietary Manager both stated that their policy requires received dates on items when they arrive, and once opened, items should be relabeled with a best-used-by date. However, the facility struggled with maintaining these practices, particularly in the freezer. The Puree Cook A mentioned that she dates the frozen meals with preparation dates but does not add a use-by date. The Dietary Manager admitted that expired items should be thrown out and that the refrigerator is checked daily for goods nearing expiration. The failure to adhere to these policies could result in food-borne illnesses, as noted in the facility's undated refrigerator and freezer policy and the U.S. Food and Drug Administration (FDA) Code (2022).
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,062 citations issued within 25 miles in the last 12 months — including the 39 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mesquite
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Town East Rehabilitation And Healthcare Center | 1.6 mi | ★★★★★ | 18 | 2 |
| Palomino Place | 2.3 mi | ★★★★★ | 13 | 1 |
| Advanced Health & Rehab Center Of Garland | 2.8 mi | ★★★★★ | 16 | 3 |
| Willowbend Nursing And Rehabilitation Center | 3 mi | ★★★★★ | 19 | 0 |
| Golden Acres Living And Rehabilitation Center | 3.3 mi | ★★★★★ | 23 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Christian Care Communities And Services Mesquite.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.