Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 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’s room and the nearby hallway had visible environmental damage, including peeled baseboards, missing laminate exposing particle board, bubbling paint, and wall damage consistent with water intrusion. The hallway also had rust-colored streaks from a wall-mounted light fixture. The Mgr stated he was aware of the damage, said the hallway issue was from a roof leak, and reported no proof that bids had been completed or that roof repairs had been hired.
Failure to Provide Written Transfer/Discharge Notices and Ombudsman Notification: The facility did not provide written transfer or discharge notices, with reasons for the move, to three residents or their representatives, and did not send copies to the State LTC Ombudsman. One resident was cognitively intact and sent to the ER after aches, pains, and incoherence; another had schizophrenia, dysphagia, and moderate cognitive impairment and was sent out for nausea and vomiting; a third had CKD, acute kidney failure, and moderate cognitive impairment and was sent out for worsening CHF. Interviews confirmed the notices were not provided.
Food Storage and Sanitation Deficiencies: Surveyors found improper waste disposal at the handwashing sink, dented cans stored with other inventory and no clear signage for the dented-can area, and multiple dry goods in unlabeled bins. In the kitchen and walk-in refrigerator, staff observed cut fruit exposed to air, spoiled and moldy produce, and swollen turkey bacon with missing discard information. Interviews showed inconsistent staff understanding of dented-can handling and produce inspection practices.
A facility failed to maintain an effective pest control program after a live roach was observed in a resident room and four live spiders were found in the dining room while residents and staff were present. Interviews also showed repeated resident reports of roaches in rooms, and staff acknowledged ongoing pest sightings despite weekly pest control visits.
A resident’s quarterly MDS did not include an active diagnosis for a large mass on his head. The resident had a BIMS score of 11/15, required dependent assistance, and was observed with a large dark gray and black scalp lesion that staff described as cancerous and likely malignant; the DON and RN stated it should have been documented in the chart and weekly skin assessments, and the care plan did not address it.
Failure to care plan a resident's unconfirmed head mass. A resident with moderate cognitive impairment and dependent care needs had a large dark gray and black mass on the upper left side of the head, but the care plan did not address it. Staff stated skin issues should be assessed, documented, reported, and added to the care plan, and the DON said the mass should have included cleaning instructions and routine care directions.
The facility failed to keep the outside garbage storage area clean and failed to ensure a dumpster and an industrial compactor were properly closed. Surveyors observed an open gated enclosure, an open compactor door with cardboard boxes outside it, an open dumpster exposing trash, and a mattress outside the dumpster. The DM stated trash was emptied weekly and that staff were expected to close dumpster lids, gates, and enclosure doors after use.
A CNA failed to change gloves and perform hand hygiene during incontinence care for a resident with kidney failure, diabetes, and impaired cognition. After cleaning the resident's genital area and buttocks, the CNA continued care without glove change or hand hygiene, despite the DON stating staff were supposed to do so and the facility policy requiring hand hygiene before and after direct resident contact.
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.
Unsafe Environmental Conditions in Resident Room and Hallway
Penalty
Summary
The facility failed to ensure a resident had a safe, clean, comfortable, and homelike environment in one room and one hallway observed for environmental concerns. In Resident #100’s room, the baseboard had peeled away from the wall and was lying on the floor in many areas around the room. The laminate covering a built-in cabinet next to the entry was missing a 4 by 4-inch area, exposing the particle board underneath. In the ensuite bathroom, a section of the wall next to the toilet appeared bulging, and the paint was bubbling away from the surface from the ceiling to the floor, with the area appearing to be water damage. In the 2100 hallway outside Resident #100’s room, the wall was observed damaged from the ceiling to the floor. The damaged area had several long rust-colored streaks and what appeared to be water damage covering a 2-foot wide by 8-foot-tall section of the wall. The Maintenance Manager stated he was very aware of the damage in the resident’s room and in the hallway, and said the hallway damage was from a roof leak that caused rust-colored streaks from the water rusting the metal of the wall-mounted light fixture. He also stated the facility had started to put bids out in the community to fix the roof and water damage, but had no physical proof that bids had been put out or answered, and that no one had been hired to make roof repairs.
Failure to Provide Written Transfer/Discharge Notices and Ombudsman Notification
Penalty
Summary
The facility failed to provide written transfer or discharge notices, including the reasons for the move, to Resident #4, Resident #38, and Resident #92 or their representatives in a language and manner they could understand. The facility also failed to send a copy of the notice to a representative of the Office of the State LTC Ombudsman for these residents. The report states these failures occurred for 3 of 6 residents reviewed for discharge planning. Resident #4 was a cognitively intact female with diagnoses including acute kidney failure, type 2 diabetes, COPD, CKD, and acute hypoxemic respiratory failure. She was sent to the hospital after reporting aches, pains, and being incoherent, and her family member was called and informed, but there was no evidence that a written transfer or discharge notice was provided to her or to the State LTC Ombudsman. During interview, Resident #4 stated she had never received a written letter when she was sent to the ER and said written information would have helped her review and keep the details for later reference. Resident #38 had diagnoses including acute pyelonephritis, gastrostomy status, dysphagia, schizophrenia, anxiety disorder, and muscle weakness, with moderate cognitive impairment and dependent assistance needs. He was sent to the hospital for nausea and vomiting, but there was no evidence that a written transfer or discharge notice was provided to him, his responsible party, or the State LTC Ombudsman. Resident #92 had diagnoses including acute kidney failure, hypertension, E. coli infection, obstructive and reflux uropathy, BPH, polyneuropathies, and CKD, with moderate cognitive impairment and substantial to maximal assistance needs. He was sent to the hospital for worsening CHF, and there was no evidence that a written transfer or discharge notice was provided to him, his responsible party, or the State LTC Ombudsman. Interviews with the Social Worker, DON, Administrator, and State LTC Ombudsman confirmed the facility did not provide the required written notices or monthly discharge information to the Ombudsman.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional food service safety standards in its only kitchen reviewed. During observations, the garbage receptacle at handwashing sink #1 contained items other than disposable paper towels, including used gloves, foam cups, plastic wrapping, and plastic bottles. The facility also had no clear policy produced for food storage and labeling requirements in the walk-in refrigerator, and the provided shelf-life list was identified as a quality tool rather than a food safety reference tool. In the dry storage room, surveyors observed canned goods with compromised seals and dents, including cans of diced pears and jellied cranberry sauce with dents on the seal or side. Several cans of cut fancy sweet potatoes were also present without best-by dates. A four-tier wire shelf contained over 10 dented and undented cans, but there was no signage identifying the designated dented-can storage area. Staff interviews showed inconsistent understanding of where dented cans belonged, and one staff member stated that the size of the dent did not matter. The DSD later stated that dents were any damage to the seal, regardless of size, and that dented cans were stored on the bottom left-hand side of the shelf. In the kitchen and walk-in refrigerator, multiple dry goods in plastic bins had no product name, open date, or use-by date. Surveyors also found cut honeydew melon exposed to air, multiple baskets of strawberries, raspberries, blueberries, and bags of grapes that were soft, mushy, and had visible white, fluffy mold growth. Additional produce and a package of turkey bacon were observed in similar condition, including swollen and distended turkey bacon with no use-by, expiration, or discard date. Staff interviews reflected that produce was visually inspected only when used or daily, but spoiled items were still present during the observations, and one staff member stated that if residents ate spoiled produce, they could become sick.
Pest Control Program Failed to Keep Resident Areas Free of Pests
Penalty
Summary
The facility failed to maintain an effective pest control program to keep the dining room and a resident room free of pests. During observation, a live roach was seen in the ensuite bathroom of Resident #100’s room, crawling on the floor at the edge of the shower stall. The room was later observed with the resident’s belongings being placed inside, and the resident was later seen lying in bed in that room while staff arranged the resident’s belongings. The resident’s room had previously been associated with roach complaints, and the administrator stated the room was supposed to be closed for maintenance issues. In the dining room, four large live spiders were observed in the resident self-service area and along the walls while 26 residents and 4 staff members were using the room. Interviews with residents and staff indicated repeated sightings of roaches in resident rooms, including reports from Resident #3’s representative, Resident #42, and Resident #59. The housekeeping manager stated she had seen small roaches around the facility over the last month, and the maintenance manager stated there had been a few reports of roaches every month. The facility’s pest control contract was active and the pest control company visited weekly, but live pests were still observed in resident and common areas.
MDS Did Not Reflect Resident’s Head Mass Diagnosis
Penalty
Summary
The facility failed to ensure Resident #7’s assessment accurately reflected his status because his quarterly MDS did not document an active diagnosis for a large mass on his head. Resident #7 was an older male admitted to the facility with diagnoses including metabolic encephalopathy, mild protein-calorie malnutrition, atherosclerotic heart disease, muscle atrophy, and dysphagia. His quarterly MDS showed a BIMS score of 11/15 and indicated he required dependent assistance with care, but the assessment did not include the head mass as an active diagnosis. Record review and observations showed the resident had a large dark gray and black mass on the upper left side of his head, described in a DON progress note as a large skin lesion on the scalp that was likely malignant and as a large skin growth approximately 3 cm x 10 cm x 3 cm with intermittent drainage and tenderness. During observation, the lesion was noted to be thickened and layered, with intact surrounding skin and no visible drainage, bleeding, or open areas. RN K stated the mass was cancerous and that the resident was on hospice, while the DON stated the diagnosis should have been documented and the mass should have been recorded during weekly skin assessments. The comprehensive care plan also did not address the unconfirmed mass on the resident’s head.
Failure to Care Plan Head Mass
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #7 that addressed an unconfirmed mass on the upper left side of his head. Resident #7 was an [AGE]-year-old male admitted to the facility with diagnoses including metabolic encephalopathy, mild protein-calorie malnutrition, atherosclerotic heart disease, muscle atrophy, and dysphagia. His quarterly MDS assessment showed a BIMS score of 11/15, indicating moderate cognitive impairment, and he required dependent assistance with care. A review of his care plan, revised on 05/15/2026, showed no care plan addressing the mass on his head. During observation, Resident #7 had a large dark gray and black mass on the upper left side of his head that appeared thickened and layered upon itself, with no visible drainage, bleeding, or open areas and intact surrounding skin. The resident stated he had previously undergone surgery for the lump but could not recall when he had last been seen by a doctor for it. Staff interviews indicated that when a resident had a skin issue, nursing staff were expected to assess the area, notify the treatment nurse or physician, document findings, and update the care plan, and the DON stated the mass should have been included in the resident's care plan with instructions for cleaning and routine care. The facility's policy stated that a significant change in condition required interdisciplinary review and/or revision to the care plan.
Improperly Secured Dumpster and Compactor Area
Penalty
Summary
The facility failed to keep the outside garbage storage area clean and failed to ensure 1 of 2 dumpsters and 1 of 1 industrial compactor were properly closed. During observation, the facility's only outside trash dumpster area had 2 dumpsters and 1 compactor behind a 3-sided wooden gate, with the back side against the facility wall and the gated door open. The compactor door was open and had 3 cardboard boxes sitting on the outside of it. Dumpster 1 of 2 had side doors open, exposing the trash inside, and 1 mattress was outside of dumpster 1 of 2. During interview, the DM stated that the dumpsters were emptied once a week by the waste management company and that staff were supposed to dispose of trash in the dumpsters and ensure the dumpster lids, gates, and enclosure doors were closed after each use. The DM explained that keeping the dumpster area secured helped prevent unauthorized access and served as a barrier against pests, rodents, and other animals. A request for the facility's policy and procedures regarding Physical Environment was made to the DSD and Administrator, but it was not provided.
Failure to Perform Hand Hygiene and Change Gloves During Incontinence Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for one resident reviewed for infection control. Resident #22 was an [AGE] year-old male admitted to the facility with diagnoses including kidney failure, diabetes, and non-Alzheimer's disease. His annual MDS assessment dated 05/01/26 showed a BIMS score of 12, indicating moderately impaired cognitive skills. His care plan dated 07/15/25 identified an ADL self-care performance deficit related to limited mobility, and noted that he was dependent on one staff member for hygiene. During an observation on 05/20/26 at 1:20 PM, CNA H performed incontinence care for Resident #22. After cleaning the resident's penis and scrotum and then cleaning bowel movement from the resident's buttocks, CNA H did not change gloves and did not perform hand hygiene before continuing care. CNA H then placed a clean brief on the resident and adjusted his pillows and blankets. In interview, CNA H said she believed gloves and hand hygiene were only needed if visible bowel movement was on her gloves and stated she was new to the facility and had only observed during her check-off for incontinence care. The DON stated staff were supposed to change gloves and perform hand hygiene during incontinence care and said CNA H had been trained to do so. The facility policy on hand washing/hand hygiene stated hand hygiene is the primary means to prevent the spread of infections and should be performed before and after direct contact with residents.
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).
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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 | ★★★★★ | 8 | 1 |
| Palomino Place | 2.3 mi | ★★★★★ | 12 | 0 |
| Advanced Health & Rehab Center Of Garland | 2.8 mi | ★★★★★ | 14 | 2 |
| Willowbend Nursing And Rehabilitation Center | 3 mi | ★★★★★ | 18 | 0 |
| Golden Acres Living And Rehabilitation Center | 3.3 mi | ★★★★★ | 24 | 0 |
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