Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Mesa View Senior Living during CMS and state inspections, most recent first.
Incomplete DNR Forms Missing Notary Dates: The facility had 4 residents with DNR forms in the record that were missing the notary completion date, even though the forms included the notary signature and printed name. The affected residents had varying medical conditions and levels of cognitive impairment, and staff interviews reflected that an incorrectly completed DNR would not be valid and could not be honored as written.
House A kitchen had multiple frozen food items stored open to air, unlabeled, undated, and not in original packaging, including breadsticks, bacon, cheese cubes, potatoes, cookie dough, onions, and unknown items in brown bags. A staff member stated she did not know what several items were and acknowledged the food issues could cause food borne illnesses. The DM stated foods should be dated and kept closed to air, and facility policy and food code required removed foods to be covered and identified with the common name.
Missing Oxygen Care Plans for Two Residents: The facility failed to include oxygen use in the comprehensive care plans for two residents with significant medical and cognitive impairments. Both residents had active oxygen orders and were observed using oxygen via NC or with oxygen equipment present, but their care plans did not address oxygen therapy. The MDS C confirmed the omission and stated oxygen should be care planned when ordered.
A resident with multiple chronic conditions, including HF and cognitive impairment, was ordered oxygen at 2-5 L/min via NC at bedtime and PRN for SOB, but was observed receiving 0.5 L/min instead. Staff verified the incorrect setting, noted it did not match the order, and the DON confirmed the oxygen was not being administered per the physician's order.
Expired insulin was found on the House B med cart with an opened/access date 35 days old, beyond the 28-day limit stated by the RN and the Lantus manufacturer instructions. RN A said the pen had expired, discarded it, and opened a new one. The DON stated insulin should be labeled appropriately and acknowledged that administering expired insulin could result in the resident not receiving the appropriate dose.
The facility failed to follow professional standards for food safety, as observed during a kitchen inspection. Multiple food items were not labeled or dated upon receipt or opening, and some packages were open to air. Interviews with staff revealed the absence of specific food handling policies, relying only on Texas Food Establishment Rules, potentially risking residents' health.
The facility did not have an RN on duty for at least 8 consecutive hours on a specific day, as required by regulations. This was confirmed through a review of RN schedules and an interview with the DON and ADM, who acknowledged the absence of an RN and the lack of specific policies for RN coverage. The DON noted that without an RN, residents needing advanced care beyond an LVN's scope might not receive proper care, especially in emergencies.
The facility failed to remove expired Bisacodyl Suppositories from the Sunset House medication cart, as observed during a survey. LVN A, responsible for checking medications, missed the expired item, which was later removed for destruction. Interviews with staff confirmed that all nurses were responsible for disposing of expired medications, which could be ineffective and potentially harmful.
A resident with Alzheimer's and other conditions was left unattended with crushed medications mixed in yogurt by a CMA, contrary to facility policy. The resident, who required supervision, was not capable of self-administering medications. The incident was confirmed through interviews and a written statement by the CMA.
Incomplete DNR Forms Missing Notary Dates
Penalty
Summary
The facility failed to ensure that Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) forms were properly completed for 4 of 17 residents reviewed for advance directives. Resident #2, Resident #4, Resident #8, and Resident #11 each had a DNR order in the record, but the DNR form for each resident was missing the date when the notary signed the document. The report states that the forms contained the notary’s signature and printed name, but not the notary completion date required for the document to be properly completed. Resident #2 was a female resident with diagnoses including epilepsy, chronic kidney disease, and hypertension, and her quarterly MDS showed a BIMS of 10 with moderate cognitive impairment and dependence with most ADLs. Resident #4 was a female resident with heart failure, atrial fibrillation, chronic combined systolic and diastolic heart failure, and COPD, and her MDS showed a BIMS of 03 with severe cognitive impairment and dependence with most ADLs. Resident #8 was a 74-year-old male with heart failure, hypertension, and benign prostatic hyperplasia, and his MDS showed a BIMS of 08 with severe cognitive impairment and assistance needs for several ADLs. Resident #11 was an 83-year-old female with Parkinson’s disease with dyskinesia, hypertension, and a history of circulatory system disease, and her admission MDS showed a BIMS of 15 with intact cognition and independence in eating, toileting, and dressing. During interviews, an LVN stated that if a DNR was not completely correct or accurate, staff would be required to provide CPR, while the ADM stated a DNR that was not completed correctly could not be honored and that administrative personnel were responsible for ensuring DNRs were completed correctly. The DON and SW also stated that incomplete DNR forms would not be valid and that a resident’s wishes might not be followed.
Unlabeled and Improperly Stored Frozen Foods
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional food service safety standards in House A kitchen. During observation of the freezer, surveyors found multiple food items that were open to air, not labeled, not dated, and not in their original packaging, including a pie shell, diced potatoes, frozen cookie dough, two brown bags of unknown food items, onions in a Ziplock bag, pastry sheets, three bags of breadsticks, a meat product with frost covering the food, a large package of bacon, and cheese cubes. One of the breadstick bags was described as slimy and greasy to the touch, and one cheese bag was open to air. A later observation of the same freezer showed the same unlabeled and open items still present, and additional items were found, including a large Ziplock bag of turkey or chicken strips that was open to air and not labeled. The House A food service staff member stated that all foods in the freezer should be labeled and dated, that she did not know what the unlabeled foods in the brown bags and the Ziplock bag of meat with frost were, and that she had been trained on how to label and date foods. She also stated she did not know why the foods had been open to air and not labeled, and said the food issues could cause food borne illnesses in residents. The DM stated she had been supervising all kitchens in the facility and that the expectation was for all foods to be dated with the receiving date and kept closed to air. She stated cooks were responsible for dating food and acknowledged that brown bags of food and meats should be labeled because the contents could not be identified otherwise. Record review showed the facility policy required food to be stored under sanitary conditions using Texas Food Establishment Rules, and another policy stated that food removed from its original package must be placed in a clean sanitized container, covered, and labeled with the name of the food and its original use by or expiration date. The cited food code and TFER provisions also required working containers of food removed from original packages to be identified with the common name of the food.
Missing Oxygen Care Plans for Two Residents
Penalty
Summary
The facility failed to develop comprehensive care plans that included oxygen use for 2 of 17 residents reviewed. Resident #4 had diagnoses including Alzheimer's disease, congestive heart failure, and chronic obstructive pulmonary disease. Her quarterly MDS dated 8/05/25 showed a BIMS of 03, indicating severe cognitive impairment, and she was dependent on staff for most ADLs. Her orders included oxygen at 2-5 liters PRN for shortness of breath, and she was listed as receiving oxygen therapy while a resident. Record review of Resident #4's care plan, initiated 1/27/2025, showed no care plan for oxygen use. During observation on 10/13/2025 at 10:22 AM, Resident #4 was in bed sleeping with her oxygen tubing rolled up next to her head while the oxygen concentrator was on. She awoke to knocking, was confused, and did not respond appropriately to questions. Resident #32 had diagnoses including Alzheimer's disease, chronic kidney disease, bipolar disorder, epilepsy, left ventricular failure, and rheumatoid arthritis. Her quarterly MDS dated 7/15/25 showed a BIMS of 99, indicating she was unable to complete the interview due to memory problems, and she was dependent on staff for most ADLs. Her orders included oxygen at 2-5 liters QHS for shortness of breath related to heart failure, and she was listed as receiving oxygen therapy while a resident. Her care plan, initiated 10/06/2020 and last revised 4/27/2025, did not address oxygen use. During observations on 10/13/2025 and 10/14/2025, she was in bed with oxygen via NC, including while sleeping peacefully. The MDS C confirmed she was responsible for care plans, verified the oxygen orders and diagnoses, and stated oxygen should be care planned, especially if there are orders, but that it had not been addressed for a while.
Incorrect Oxygen Dose for Resident
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not ensured for Resident #32. Resident #32 was an [AGE]-year-old female with diagnoses including Alzheimer's disease, chronic kidney disease, bipolar disorder, epilepsy, left ventricular failure, and rheumatoid arthritis. Her quarterly MDS dated 7/15/25 indicated a BIMS of 99, showing she was unable to complete the interview due to memory problems, and that she was dependent on staff for most ADLs. The record also identified her as receiving oxygen therapy while a resident. Her physician orders included oxygen at 2-5 liters via nasal cannula at bedtime and as needed for shortness of breath related to heart failure. However, the care plan had no oxygen use care plan, and during observations on 10/13/2025 and 10/14/2025 she was seen in bed with oxygen running at 0.5 L/min via nasal cannula. During interview, MA B verified the oxygen was set at 0.5 L/min, checked the order, and stated the dose was not correct and needed to be increased. The DON later confirmed staff were not following the physician's order when oxygen was administered at 0.5 L/min and stated nurses or medication aides were responsible for checking that the oxygen was set at the correct level.
Expired insulin pen found on medication cart
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when the facility failed to provide accurate dispensing and administering of insulin for 1 of 7 insulins reviewed. During observation of the House B medication cart, an insulin pen was found with an opened/access date that was 35 days old. RN A stated the pen had expired, explained that insulin should be discarded 28 days after it is opened/accessed, and reported that the resident received a scheduled evening dose. RN A discarded the expired pen and opened a new one, then labeled the new pen with the opened/accessed date. RN A stated that using an expired medication such as insulin could result in the medication losing its effectiveness and could affect the resident's hyperglycemic or hypoglycemic reactions. The DON stated that insulins should be labeled with required information, including the resident's name and dose, and that a multidose vial should be labeled when first removed from the box. The DON also stated that administering expired insulin could result in the resident not receiving the appropriate dose of medication. Facility policy required checking the expiration date and recording the expiration date and time when opening a new vial, and manufacturer instructions for Lantus stated that an opened pen should be thrown away after 28 days, even if insulin remains.
Food Safety Deficiency in Kitchen Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a kitchen inspection. The inspection revealed multiple instances of food items not being labeled or dated upon receipt or opening. Specific items included a 4-pound bag of cheesecake filling mix, a 10-pound bag of tri-colored rotini, and various other food products such as spaghetti noodles, cracker crumbs, and wild rice blend, all lacking dates of receipt. Additionally, several items, including fresh grapes, shredded cheddar cheese, and turkey lunch meat, were not dated when opened. Furthermore, some food packages, like a partial bag of frozen pancakes and tart pastry shells, were found open to air, which could compromise their safety and quality. Interviews with the Dietary Manager and the Administrator highlighted the potential negative outcomes of these practices, such as the risk of residents consuming expired foods and the loss of nutritional value due to exposure to air. The Administrator admitted that the facility lacked specific policies and procedures for food handling and safety, relying solely on the Texas Food Establishment Rules (TFER). This lack of proper food safety protocols and documentation could place residents at risk of food-borne illnesses.
Failure to Ensure RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required by regulations. Specifically, on August 24, 2024, there was no RN coverage for a 24-hour period. This deficiency was identified through a review of RN schedules for August, September, October, and November 2024. During an interview on December 11, 2024, the Director of Nursing (DON) and the Administrator (ADM) confirmed the absence of an RN on the specified date. The ADM acknowledged the lack of specific policies and procedures regarding RN coverage beyond state and federal regulations. The DON expressed concerns that without an RN, residents requiring advanced care beyond the scope of a Licensed Vocational Nurse (LVN) might not receive proper care, particularly in emergencies, potentially affecting their quality of life.
Expired Medications Found in Sunset House Medication Cart
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled according to currently accepted professional principles, specifically on the medication cart at Sunset House. During an observation, Bisacodyl Suppositories with an expiration date of 11/2024 were found in the medication cart, indicating they were not removed after expiration. LVN A, who was responsible for checking and removing expired medications, acknowledged missing the expired medication and subsequently removed it for destruction. Interviews with LVN A, LVN B, and MA C revealed that all nurses were responsible for ensuring expired medications were disposed of and removed from the medication cart. They acknowledged that expired medications could be ineffective and potentially harmful to residents. A review of the facility's 'Storage of Medications' policy confirmed that the facility should not use outdated drugs and that such drugs should be returned to the pharmacy or destroyed.
Improper Medication Administration
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident, as evidenced by the actions of a Certified Medication Aide (CMA) who administered medications improperly. The CMA crushed the resident's medications and mixed them with yogurt and whipped cream, then left the resident unattended with the medication mixture. This incident was confirmed through interviews and a written statement by the CMA. The resident, who has Alzheimer's Disease and other medical conditions, was cognitively significantly impaired and required supervision, as indicated by her care plan and medical records. The resident's medications included Seroquel, Tramadol, Ativan, and Lisinopril, which were to be administered as per physician's orders. The CMA admitted to leaving the resident alone with the medicated yogurt while attending to other residents, which was against the facility's policy that requires medications to be administered safely and timely. The resident was monitored afterward and showed no adverse physical symptoms. The facility's policy also states that residents may only self-administer medications if deemed capable by the care planning team, which was not the case for this resident.
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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.
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Nursing homes near Canadian
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wheeler Nursing & Rehabilitation | 30.2 mi | ★★★★★ | 6 | 0 |
| Shattuck Nursing Center | 38.4 mi | ★★★★★ | 0 | 0 |
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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.