Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Mesquite Post Acute Care during CMS and state inspections, most recent first.
Residents repeatedly reported waiting 30 to 60 minutes for call lights to be answered, including when they needed help getting out of bed, dressing, or using the restroom. Resident council notes documented ongoing concerns about timely response, and one note stated staff were turning off call lights and leaving without addressing issues. The charge nurse for one hall stated she had no CNA help, while the CNA assigned there said she was the only CNA on the hall and could take up to 20 minutes to respond. The DON and ADM stated there was no written policy for staffing or call light response, and both acknowledged that 30 minutes was too long.
Medication Administration Errors and Late Doses: Surveyors found a medication error rate above the allowed threshold after observing late doses and an underdose for several residents. An LPN was unable to administer ordered antidepressant, antihypertensive, and bladder medications because they were not available on the cart or in the emergency kit, and the LPN also gave only half of the ordered Clozapine dose after misreading the order. The residents involved had diagnoses including neurocognitive disorder, dementia, MS, schizophrenia, depression, hypertension, and DM.
Medication carts on multiple halls were found unsecured and containing loose pills. A charge nurse left one cart unlocked while passing meds, an LVN found loose tablets in another cart while helping a new med aide, and a med aide cart on another hall was also left unattended with the lock popped out and later found to contain additional loose pills. The DON and ADM stated carts were expected to be locked when unattended and medications stored securely.
Food Not Served at Proper Temperature or Palatable: The facility failed to provide breakfast items that were palatable and at an appetizing temperature across regular, mechanical soft, and pureed trays. Surveyors observed cold/lukewarm sausage, thick and hard oatmeal, lukewarm sausage and gravy, and cold/lukewarm pureed items with an incorrect consistency. Several residents reported food was cold, bland, lousy, or undercooked, and the DM acknowledged prior complaints about oatmeal and cream of wheat being too thick.
Improper Food Storage and Kitchen Sanitation: Surveyors observed multiple food items in the refrigerator, freezer, and pantry that were not properly sealed, labeled, or dated, including meat, cheese, noodles, cereal, fries, and soy sauce. Dirty refrigerator handles, oven handles, and a microwave with food residue were also noted. The DM and ADM stated food should be labeled, sealed, and stored properly, and that kitchen surfaces and equipment should be kept clean and sanitized.
An LPN left a medication cart unattended with an unlocked computer screen displaying a resident's EMAR and a clipboard with residents' vital results faced-up on top of the cart. The charge nurse stated the screen should have been locked and the paperwork covered when stepping away, and the DON and ADM confirmed resident health information was expected to remain private and confidential.
A resident with severely impaired cognition and COPD had a portable oxygen tank found free-standing on a dresser in his room, with staff stating it should have been stored in the oxygen room or in a cart/bag when in use. In Shower Room A, a Lemon Disinfectant spray bottle was found hanging by the toilet, and the DON and ADM stated cleaning chemicals should be stored locked in carts or closets when not in use.
Pureed Foods Served in Improper Consistency: A DM prepared pureed breakfast and lunch items that were observed to contain chunks and a soup-like consistency rather than holding form. The ADM agreed the sausage with gravy and mixed vegetables were not the correct puree consistency, and the DM stated pureed food should be smooth and able to hold form.
Failure to Use EBP PPE During Resident Care: Staff did not wear required gowns and gloves while providing direct care to residents on EBP, including dressing, transferring, changing linens, and combing hair. One resident had wounds, a dialysis port, and an ostomy, and another had an indwelling catheter, colostomy, and a pressure ulcer. The DON and ADM stated gowns and gloves were required for these high-contact care activities, but CNAs acknowledged they did not follow the EBP requirements.
Insufficient Room Size in Multiple Resident Bedrooms: The facility failed to ensure four semi-private rooms met the required minimum of 80 sq. ft. per resident. The ADM stated the rooms were in an unused area awaiting renovation, but they remained listed on the bed classification form. The ADM also stated the facility had no policy for the room size waiver and confirmed the rooms were not planned to open in the near future.
Three residents with cognitive and behavioral health diagnoses were involved in separate incidents of physical aggression toward others. Although staff responded to each event with immediate interventions such as monitoring and separation, the care plans for these residents were not updated to reflect the new behaviors or to include specific, measurable interventions. Facility staff and leadership acknowledged that while the incidents were discussed in meetings, the care plans were not revised to address the aggressive behaviors.
The facility failed to inform 12 of 20 residents about their rights and procedures for filing grievances. Residents were unaware of how to file grievances, lacked access to forms, and did not know about their right to a written decision. Observations showed inadequate posting of grievance procedures and inaccessible grievance forms. The Administrator acknowledged the system's shortcomings and the lack of resident education on the grievance process.
The facility failed to log controlled drugs awaiting disposal, leading to inaccuracies in drug reconciliation. Unlogged medications were found in storage, and the DON was unaware of the logging requirement. Additionally, expired medications were found in a medication cart, indicating lapses in checks. Facility policies require logging and secure storage of medications, but these were not followed, risking potential negative outcomes.
A resident's OOH-DNR form was incomplete, lacking necessary witness and notary signatures, which could invalidate the document. The facility lacked a social worker to complete these forms, and the DON was not trained in their completion. This oversight could lead to the resident's end-of-life wishes not being honored during emergencies.
The facility failed to seal foods stored in the refrigerator, as observed with slaw, lunch meat, and sliced cheese in unsealed plastic bags. Interviews with the DM and ADM confirmed that all food should be sealed, and staff had been trained accordingly. The facility's policy requires daily checks of refrigerators, which were not effectively implemented, leading to potential risks of food contamination.
A LTC facility failed to maintain an effective infection control program, as evidenced by two incidents. An LVN did not sanitize his hands between glove changes during wound care for a resident, risking cross-contamination. Additionally, a CNA did not wear a gown while providing care to a resident on Enhanced Barrier Precautions, contrary to facility policy. Both staff members had received recent training on infection control but did not adhere to protocols.
The facility failed to provide the required minimum of 80 square feet per resident in four semi-private rooms, despite having a waiver for these room size requirements. The rooms were unoccupied at the time of the survey due to ongoing renovations, and the ADM expressed the intention to continue the waiver. No policy was provided regarding room size compliance.
A resident with a history of behavioral issues was slapped on the arm by a CNA after the resident spat at her. The incident was witnessed by a social worker who intervened and reported it to the administration. The CNA admitted to the action, citing it as a knee-jerk reaction, despite being aware of the facility's abuse prevention policies.
The facility failed to maintain an infection control program, leading to potential infection risks for two residents. An LPN did not change gloves or wash hands properly during wound care, and interviews confirmed non-compliance with handwashing policies.
Delayed Call Light Response and Insufficient Nursing Staffing
Penalty
Summary
The facility failed to provide sufficient nursing staff with the appropriate competencies and skill sets to meet resident needs and to answer call lights in a timely manner for 7 of 23 confidential residents reviewed. Multiple residents reported waiting 30 to 45 minutes, and in some cases 45 minutes to 1 hour, for staff to respond to call lights. Several residents stated they needed help getting out of bed, dressing, or using the restroom, and they described the delays as frustrating, too long, and ongoing across all shifts. Resident Council meeting notes documented repeated concerns about nursing response to call lights, including concerns about answering lights in a timely manner and night CNA response. One note also recorded a concern that staff were turning off call lights and leaving without addressing the issue. Residents stated they had complained about the delays, but felt nothing had changed. One resident said they sometimes walked to the nurses’ station to find help after waiting more than 30 minutes, and another said they were afraid their roommate might fall because of the long response time. During interviews, the charge nurse for Hall 200 stated she had no nursing assistants to help her with nursing duties and was busy answering call lights, changing briefs and linens, answering the phone, checking food trays, and documenting vital signs, which prevented timely response. A CNA assigned to Hall 200 stated she was the only CNA on the hall, that it was hard to answer call lights timely, and that response could take up to 20 minutes when she was providing care to another resident. The DON and ADM both stated there was no written policy for staffing or call light response, and both acknowledged that 30 minutes was too long for a call light to wait for response.
Medication Administration Errors and Late Doses
Penalty
Summary
The facility failed to keep its medication error rate below 5 percent. Surveyors found a medication error rate of 15.38% based on 4 errors out of 26 opportunities, involving 4 of 5 residents reviewed for medication administration. The errors included late administration of Escitalopram for one resident, late administration of Hydrochlorothiazide and Oxybutynin for another resident, late administration of Citalopram for a third resident, and an incorrect dose of Clozapine given to a fourth resident. One resident with frontotemporal neurocognitive disorder, major depressive disorder, and hypertension had an order for Escitalopram 20 mg daily at 0600, but during observation the LVN was unable to give the medication because it was not available on the medication cart or in the emergency kit. The LVN stated the medication should have been available and that it had been ordered but had not yet been delivered by the pharmacy. Another resident with multiple sclerosis, dementia, and hypertension had orders for Hydrochlorothiazide 25 mg daily and Oxybutynin 5 mg daily at 0600, but both medications were also unavailable on the cart or in the emergency kit during observation, and the LVN stated they should have been available for dispensing. A third resident with Alzheimer’s disease, dementia, and Type II diabetes mellitus had an order for Citalopram 20 mg daily at 0600, but the medication was not available on the cart or in the emergency kit when the LVN attempted administration. A fourth resident with paranoid schizophrenia, Type II diabetes mellitus, and major depressive disorder had an order for Clozapine 100 mg twice daily, but the LVN administered one half tablet for a total dose of 50 mg. During interview, the LVN stated she read the order wrong and should have given two half tablets to equal the ordered dose. The DON and ADM stated staff were expected to have medications available and to administer them accurately according to physician orders, and the facility policy required medication orders to be reviewed and verified before administration.
Medication Carts Left Unlocked and Contained Loose Pills
Penalty
Summary
The facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional principles for three medication carts: the Hall 200 Nurse Medication Cart, the Hall 200 Medication Aide Cart, and the Hall 300 Medication Aide Cart. During observation, the Hall 200 Nurse Medication Cart was found in the hallway with the lock popped out and no staff member present. A charge nurse identified herself as responsible for the cart and stated she had been in the process of passing medications and had not locked the cart when she stepped away from it. The surveyor was able to open all drawers, and the cart contained blister packs, bottles of medications, and medical supplies such as syringes. The Hall 200 Medication Aide Cart was observed with six loose pills in the drawers while an LVN was present. The loose medications were identified by the DON as sertraline 100 mg, atorvastatin 20 mg, potassium chloride 10 mEq, and cyclobenzaprine 10 mg. The LVN stated she was responsible for the cart while on duty and had not yet checked it that morning because she was helping a new medication aide pass medications. She stated the cart should not contain loose pills and that she was responsible for checking it for loose or expired medications. The Hall 300 Medication Aide Cart was also observed unattended with the lock popped out, and a resident in a wheelchair was nearby. The surveyor was able to access all drawers, including the controlled medications drawer, and observed blister packs, liquid medication, and OTC medications on the cart. Later, nine loose pills were found in the drawers and were identified by the ADON as metoprolol 25 mg, atorvastatin 20 mg, tizanidine 2 mg, carvedilol 25 mg, pantoprazole 40 mg, gabapentin 100 mg, and levetiracetam 750 mg. The medication aide responsible for the cart stated it should be locked when not supervised and should not contain loose medications. The DON and ADM stated medication carts were expected to be locked when unattended and that staff assigned to the carts were responsible for secure storage.
Food Not Served at Proper Temperature or Palatable
Penalty
Summary
The facility failed to ensure that food provided for breakfast was palatable, attractive, and at a safe and appetizing temperature for 3 of 3 food forms reviewed: regular, mechanical soft, and pureed. During observation on 05/20/26, test trays were sampled and the regular tray included sausage that was cold/lukewarm and oatmeal that was dry, thick, and had some hard pieces. The mechanical soft tray had sausage and gravy that was lukewarm. The pureed tray had sausage with gravy that was cold/lukewarm and had a soup-like consistency, and cream of wheat that was cold/lukewarm. The ADM stated the oatmeal was thick and the puree sausage and gravy consistency was not correct. During confidential interviews, 3 of 8 residents voiced concerns about food palatability, stating the food was cold and lacked flavor, was lousy and not good, and was not good, lacked seasoning, and tortillas were served raw. At the resident council meeting, a resident stated the oatmeal served in the morning was hard and undercooked. The DM stated residents had complained before about oatmeal and cream of wheat being too thick, and she believed oatmeal thickened while sitting after preparation. The resident council notes dated 04/13/26 also documented that soups were cold and sometimes bland. The facility policy stated food items would be prepared to conserve maximum nutritive value, develop and enhance flavor, and keep free of harmful organisms and substances.
Improper Food Storage and Kitchen Sanitation
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. During the initial kitchen tour, surveyors observed dirty refrigerator handles with a dry hard/sticky substance, a white hard food item and a small circular white/grey food item in the refrigerator with no label or date, a box/bag of bacon that was not properly sealed and had no date, a bag of shredded cheese that was not properly sealed and was dated 5/11/26 with a use-by date of 5/13/26, five blocks of yellow cheese dated 5/18/26 with no other label, and a bag of French fries in the freezer that was not properly sealed and undated. Surveyors also observed two dirty oven handles with grease spots and oil, a box of spaghetti noodles and a bag of cornflakes that were not properly sealed and undated in the pantry, and a gallon of soy sauce on the pantry shelf with no lid, not properly sealed, and no date on the bottle. A dirty microwave handle and the inside top of the microwave also had dry food on them. During interviews, the DM stated she did not know why some foods were not stored properly or why the refrigerator, oven handles, and microwave were dirty, and said the evening shift handled more of the clean duties while the morning shift was responsible for sealing and labeling food properly. On a return visit, surveyors found a box of quick cream of wheat dated 05/12/26 not properly sealed on a shelf by the refrigerators. The DM later stated all food stored in the kitchen should be labeled with an open and use-by date and fully sealed, but she did not know when kitchen staff were last trained on storing, labeling, and cleanliness. The ADM stated food was expected to be labeled and stored properly, properly sealed so no air could get in, and that kitchen staff were trained to follow a regular cleaning and deep cleaning schedule. The facility policy titled General Food Preparation and Handling stated the kitchen would be kept neat and orderly, surfaces and equipment would be cleaned and sanitized as appropriate, and foods would be received, checked, and stored properly.
Unsecured Medication Cart Exposed Resident EMAR and Vital Records
Penalty
Summary
The facility failed to respect a resident's right to personal privacy and confidentiality of medical records when the Hall 200 Nurse Medication Cart was left unattended with an unlocked computer screen displaying a resident's EMAR. At the same time, a clipboard containing a list of residents' vital results was left faced-up on top of the cart, exposing resident information in the hallway while two maintenance staff were working nearby. During the observation, LVN D stated she was the charge nurse assigned to the Hall 200 Nurse Medication Cart and said she had been passing medications and taking vitals while assisting a confused resident who wanted pain medication. She stated the computer screen was supposed to be locked and resident information was supposed to be covered when left unattended, and that she was supposed to lock the computer and flip over the list of vitals when stepping away. She also stated this was a HIPAA violation and that she had been trained not to leave resident information exposed. A later observation showed the same cart still had the list of residents and their vital results faced-up on top of it with no staff present. The DON stated resident health and care information was only to be shared with approved persons and that computer screens and documents should be locked up so passersby could not see them when staff stepped away. The ADM also stated screens should have been shut down and paperwork covered for privacy when staff walked away from medication carts, and the facility policy stated residents have the right to personal privacy and confidentiality of personal and medical records.
Improper Storage of Oxygen Tank and Disinfectant Chemical
Penalty
Summary
The facility failed to keep the resident environment free of accident hazards for Resident #54 and in Shower Room A. Resident #54 was an [AGE]-year-old male admitted and readmitted to the facility with diagnoses including Wernicke's encephalopathy, reduced mobility, and COPD. His quarterly MDS dated 03/26/26 showed a BIMS score of 03, indicating severely impaired cognition. His order summary included oxygen 2-4 LPM via nasal cannula as needed to keep SpO2 greater than 90% related to COPD. During observations on 05/19/26 and 05/20/26, a portable oxygen tank was found free-standing and sitting on a long dresser in his room, with clothes scattered around it. LVN C stated she did not know why the tank was on the dresser and said portable oxygen tanks were supposed to be stored in the oxygen storage room with the racks. In Shower Room A, a spray bottle labeled Lemon Disinfectant with a warning label stating keep out of reach of children was observed hanging on the rail by the toilet, with a small amount of liquid and bubbles in the bottom of the bottle. The DON stated she did not know why the disinfectant spray was being stored in the shower room and said it could cause injury if residents got it on them or ingested it. The DON and ADM stated portable oxygen tanks should be stored in the oxygen room when not in use and should not be stored free-standing, and the ADM stated cleaning chemicals should be stored locked in carts or cleaning closets when not in use. Facility policies reviewed included Oxygen Storage, which required oxygen cylinders to be physically supported in a stand, rack, or chained or strapped to the wall, and Safety Management: Hazardous Chemicals, which required chemicals to be properly stored, labeled, maintained, and handled according to manufacturer guidelines.
Pureed Foods Served in Improper Consistency
Penalty
Summary
The facility failed to ensure that pureed foods were prepared in a form designed to meet individual needs for 2 observed meals, breakfast and lunch. During the breakfast observation on 05/20/26 at 7:40 AM, the DM prepared pureed eggs, cream of wheat, and pureed sausage with gravy and provided a sample tray. When the surveyor tasted the pureed sausage with gravy, it contained small chunks of meat and was in a soup-like form, meaning it did not hold shape. During an interview at 7:58 AM, the ADM agreed that the sausage and gravy was not the correct consistency for puree form. During the lunch observation on 05/20/26 at 12:00 PM, the DM prepared pureed chicken, mashed potatoes, bread, and mixed vegetables and provided a sample tray. When the surveyors tasted the pureed mixed vegetables, they found small chunks and a soup-like form, meaning it did not hold shape. During an interview at 12:10 PM, the ADM agreed that the mixed vegetables were not the correct consistency for puree form. On 05/21/26, the DM stated she had been trained on puree form and to mix it so there were no chunks of food, and that pureed food should be smooth and able to hold form. The ADM stated she expected pureed foods to be safe and proper in consistency every time they were sent to residents and did not know why the foods were sent out when not in proper form.
Failure to Use EBP PPE During Resident Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for residents on Enhanced Barrier Precautions (EBP). Resident #2 had diagnoses including a stage 4 pressure ulcer, acute kidney failure, urinary tract infections, ileostomy status, pseudomonas, resistance to carbapenem, and amputations. The resident’s care plan and physician’s orders identified EBP for wounds, a dialysis port, and an ostomy/colostomy. Resident #4 was also in the same room, had intact cognition, and had no EBP order. During observation, CNA E assisted Resident #2 with dressing, transferred the resident from bed to wheelchair, handed the resident belongings, and then fixed both residents’ beds while not wearing a gown. The room door had EBP signage posted. CNA E later stated she was trained on EBP, knew gowns and gloves were required for direct care and handling linens, and acknowledged she did not wear PPE during the care provided. Resident #26 had diagnoses including anoxic brain damage, COPD, colostomy status, an indwelling catheter, and a stage 3 pressure ulcer. The resident’s care plan and physician’s orders identified EBP for wounds, the indwelling catheter, and colostomy care. During observation, CNA F was seen combing Resident #26’s hair while the resident sat in a wheelchair, and CNA F was not wearing a gown or gloves. EBP signage was posted on the door. CNA F stated she was trained to wear gowns and gloves when entering rooms to provide care or touch belongings, and she acknowledged she should have worn PPE when combing the resident’s hair. She also stated she had not been in-serviced about a change in where PPE was stored. The DON stated staff were expected to implement EBP when they had contact with residents on EBP, including close contact, perineal care, handling linens, and direct care activities. The DON also stated staff should wear gowns and gloves for residents on EBP and that combing hair was direct contact requiring EBP. The ADM stated staff were to wear the appropriate gown and gloves when providing care to residents on EBP and complete hand hygiene before entering and after exiting those rooms. The facility’s EBP signage stated staff must wear gloves and a gown for high-contact resident care activities including dressing, transferring, changing linens, hygiene, and device care, and the facility policy stated EBP required gown and glove use for residents with wounds and/or indwelling medical devices during high-contact care activities.
Insufficient Room Size in Multiple Resident Bedrooms
Penalty
Summary
The facility failed to provide at least 80 square feet per resident in multiple resident bedrooms for Rooms 407, 602, 604, and 611, which were identified as semi-private rooms for two residents on the Texas Health and Human Services Form 3740 Bed Classifications dated 05/20/26. During the entrance conference on 05/19/26, the ADM stated the facility would need the Texas Health and Human Services Form 3762 Room Size Waiver for several rooms at the facility and explained that the rooms were in a part of the facility not in use and awaiting renovations, but were still listed on the bed classification form. During interview on 05/21/26, the ADM stated the facility did not have a policy for the room size waiver and followed state regulations for room sizes. The ADM later confirmed that Rooms 407, 602, 604, and 611 were still listed on the bed classification form and that the facility did not have plans to open the rooms in the near future. The ADM also stated the long-term goals were to renovate and make sure all rooms were up to date. Measurements taken in the unused rooms showed square footage of 141.81, 155.04, 151.59, and 155.1 square feet, respectively, while the rooms were not occupied.
Failure to Update Care Plans After Resident-to-Resident Aggression
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents following incidents of resident-to-resident aggression. Each of these residents had documented episodes of physical aggression toward other residents, which were not subsequently addressed in their care plans through updated goals or interventions. Despite the incidents being discussed in daily and weekly meetings, the care plans were not revised to reflect the new behavioral concerns, and the necessary interventions were not documented for staff reference. For the first resident, who had diagnoses including dementia and intermittent explosive disorder, an incident of aggression occurred, and while immediate actions such as Q15 minute monitoring and provider notification were taken, the care plan was not updated to address the aggressive behavior. The second resident, with Alzheimer's and a history of behavioral symptoms, also exhibited aggression toward another resident. Although this resident's care plan included a general focus on behavioral symptoms, it was not revised to specifically address the new incident of aggression or to add targeted interventions. The third resident, who had multiple psychiatric diagnoses and was hard of hearing, was involved in an altercation where he struck another resident. While staff responded by separating the residents and implementing monitoring, the care plan was not updated to reflect the incident or to include new strategies for managing such behaviors. Interviews with facility staff and leadership confirmed that the incidents were discussed but not thoroughly documented in the care plans, and there was a lack of clarity regarding responsibility for timely care plan revisions following behavioral incidents.
Failure to Inform Residents of Grievance Procedures
Penalty
Summary
The facility failed to provide information to residents and their representatives on their rights related to filing grievances. This deficiency was identified for 12 out of 20 confidential residents, who were not informed about the grievance procedures, did not have access to grievance forms, and were unaware of their right to file grievances anonymously. The residents also did not know who the grievance officer was, how to file a grievance, or their right to receive a written decision regarding their grievances. These issues were highlighted during a Resident Council meeting where residents expressed their lack of knowledge about the grievance process. Observations revealed that the facility did not have instructions regarding grievance procedures posted in prominent locations. Grievance forms were placed in a manila folder on a bulletin board near the nurses' station, but the folder was not accessible to residents in wheelchairs. Additionally, there was an unlabeled wire basket outside the vacant Social Worker's office, which was not covered or secure, for completed grievance forms. The facility's Administrator, who was also the grievance officer, acknowledged the inadequacy of the current system and the lack of resident education on the grievance process. The facility's grievance policy, last updated in 2023, outlines the procedure for filing grievances, including the right to file anonymously and the requirement to provide a written decision within three working days. However, the policy was not effectively communicated to the residents, leading to the deficiency. The Administrator admitted that the grievance process was not discussed in Resident Council meetings and that the current system was not successful in informing residents about their rights and the grievance process.
Deficiencies in Controlled Drug Management and Expired Medication Handling
Penalty
Summary
The facility failed to establish a system for the receipt and disposition of controlled drugs, which led to inaccuracies in drug reconciliation and record-keeping. During an observation, unlogged controlled medications awaiting disposal were found in the storage area. The Director of Nursing (DON) was unaware that these medications needed to be logged upon receipt, prior to their destruction with the pharmacist. The Clinical Resource Nurse confirmed that best practice involves logging discontinued controlled medications upon receipt. The DON admitted to being overwhelmed due to recent changes in facility ownership and her new position, which contributed to the oversight. Additionally, the facility failed to ensure that expired medications were not kept in Medication Cart A. An expired bottle of Vitamin B-12 was found during an observation of the cart. The DON stated that the responsibility for checking medication carts for expired medications lies with the DON, ADON, and nurses, and that audits are conducted regularly. However, the expired medication was missed during recent checks, indicating a lapse in the process. The facility's policies on discontinued medications and disposal of medications require that medications awaiting disposal be logged and stored securely. The policies also mandate that controlled substances be handled, stored, and disposed of according to federal and state regulations. The failure to log and properly manage controlled medications, as well as the presence of expired medications in the cart, could lead to potential negative outcomes such as missing medications and reduced therapeutic effects.
Incomplete OOH-DNR Form for a Resident
Penalty
Summary
The facility failed to ensure that all residents had the right to formulate an advance directive, specifically for one resident whose Out of Hospital Do Not Resuscitate (OOH-DNR) form was missing required information. The resident, an elderly female with multiple diagnoses including peripheral vascular disease, diabetes, schizoaffective disorder, and dementia, had a DNR order noted in her records. However, her OOH-DNR form lacked necessary witness names, signatures, and a notary signature, rendering it incomplete and invalid. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that the facility did not have a social worker, who was responsible for completing the OOH-DNR forms. The DON admitted to not being trained on completing these forms and was unaware of the incomplete status of the resident's OOH-DNR. The ADM confirmed the responsibility of the nursing staff and the DON in ensuring the completeness of these forms but was also unaware of any incomplete forms. The lack of a complete OOH-DNR form could result in the resident's end-of-life wishes not being honored during an emergency.
Failure to Seal Food in Refrigerator
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not sealing foods stored in the refrigerator. During an initial observation of the kitchen, it was noted that slaw and lunch meat were stored in unsealed plastic bags. A follow-up visit revealed that sliced cheese was also stored in an unsealed plastic bag. These observations indicate a lapse in maintaining sanitary conditions for food storage, which could lead to food contamination and foodborne illness. Interviews with the dietary manager (DM) and the administrator (ADM) confirmed that all food in the refrigerator should be sealed, and that all staff had been trained to follow this protocol. The DM and ADM acknowledged the potential negative outcomes of not sealing food, such as food spoilage and cross-contamination. The facility's policy on food storage requires that the dietary manager or a designee check refrigerators and freezers daily to ensure compliance with sanitary conditions, but this was not effectively implemented, leading to the observed deficiencies.
Infection Control Lapses in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by two specific incidents involving residents. In the first incident, a Licensed Vocational Nurse (LVN) did not sanitize his hands between glove changes while performing wound care on a resident with a skin integrity impairment on her left foot. Despite being trained on proper hand hygiene, the LVN admitted to forgetting to use the hand sanitizer available on his cart, which could lead to cross-contamination and infection. In the second incident, a Certified Nursing Assistant (CNA) did not wear a gown while providing incontinent care to a resident on Enhanced Barrier Precautions (EBP) due to a stage 3 pressure ulcer. The CNA acknowledged her mistake, stating she realized the error after starting the care. The facility's policy required the use of gowns and gloves for high-contact care activities, such as changing briefs, to prevent the spread of infections, including drug-resistant organisms. The Director of Nursing (DON) and the Administrator were unaware of these lapses in infection control practices. Both staff members involved had attended recent in-service training on hand hygiene and infection control, yet failed to adhere to the protocols. The facility's policies clearly outlined the necessary procedures for hand hygiene and EBP, emphasizing the importance of using personal protective equipment (PPE) to prevent cross-contamination and the spread of communicable diseases.
Failure to Meet Room Size Requirements
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in multiple resident bedrooms for four semi-private rooms, specifically Rooms #407, 602, 604, and 611. This deficiency was identified through observation, interview, and record review. The facility had previously obtained a waiver for these room size requirements, as documented in the CASPER 3 facility assessment report and the Room Size Waiver for Facilities dated 02/15/24. During the survey, it was noted that these rooms were not currently occupied, as confirmed by the facility's administrator (ADM), who expressed the intention to continue the waiver for these rooms. The ADM stated that the rooms had been under a waiver in the past and were not in use at the time of the survey due to ongoing renovations. The rooms are intended to be used again once renovations are complete and the unit is reopened. Despite the waiver, the facility did not provide a policy related to room size, with the ADM indicating that they followed life safety regulations concerning room size. The lack of compliance with the minimum square footage requirement could potentially place residents at risk of crowding and complicate the provision of care, although this risk was not directly observed as the rooms were unoccupied during the survey.
Resident Abuse Incident by CNA
Penalty
Summary
The facility failed to ensure a safe environment free from abuse for a resident when a social worker witnessed a certified nursing assistant (CNA) slap the resident on the arm. This incident occurred after the resident approached the nurse's station and spat at the CNA, prompting the CNA to react by slapping the resident's arm. The social worker immediately intervened, informed the CNA that such actions were unacceptable, and reported the incident to the administrator and director of nursing. The resident involved in the incident was a male with a history of autistic disorder, symptomatic epilepsy, and bipolar disorder. His care plan indicated a potential for adverse behaviors, including verbal and physical aggression. The resident's cognitive skills for decision-making were noted as modified dependence, with physical and verbal behaviors directed towards others occurring 1-3 days a week. Despite these challenges, the facility failed to protect the resident from abuse by staff. Interviews with the CNA, social worker, and other staff confirmed the occurrence of the incident. The CNA admitted to the action, describing it as a knee-jerk reaction, and acknowledged awareness of the facility's abuse policies. The facility's policy on abuse prevention clearly states that residents have the right to be free from abuse, and staff are trained regularly on these protocols. However, the incident demonstrated a lapse in adherence to these policies, resulting in a deficiency in protecting the resident from abuse.
Infection Control Deficiency
Penalty
Summary
The facility failed to maintain an infection control program, leading to potential risks for infection and cross-contamination for two residents. LVN A did not change her gloves or wash her hands properly during wound care for Resident #1, who had a history of peripheral vascular disease, dementia, type 2 diabetes, and other conditions. Specifically, LVN A did not change gloves or wash hands after cleaning wounds on the resident's chest, left hip, and left ischium, and applied new dressings with contaminated gloves. Similarly, during wound care for Resident #2, who had a history of Alzheimer's, hyperlipidemia, and major depressive disorder, LVN A failed to use proper handwashing techniques. She washed her hands for less than the required 20 seconds and only washed her fingertips. This improper handwashing occurred before and after removing soiled dressings and before applying new dressings to the resident's coccyx wound. Interviews with LVN A, the DON, and the ADM confirmed that the facility's handwashing policy was not followed. LVN A admitted to being trained on proper handwashing but did not adhere to the guidelines during the observed wound care. The DON and ADM both acknowledged the importance of proper handwashing and glove changes to prevent infection but were unaware of the non-compliance until the survey.
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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 Lubbock
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mi Casita Nursing And Rehabilitation Center | 0.2 mi | ★★★★★ | 15 | 0 |
| Lakeside Rehabilitation And Care Center | 0.6 mi | ★★★★★ | 7 | 0 |
| Lubbock Health Care Center | 0.7 mi | ★★★★★ | 6 | 0 |
| Southern Specialty Rehab & Nursing | 0.8 mi | ★★★★★ | 13 | 2 |
| Avir At Lubbock | 1.4 mi | ★★★★★ | 17 | 3 |
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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.