Average — CMS composite of the measures below.
A standard survey is most likely before 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 Mesquite Village Wellness & Rehabilitation during CMS and state inspections, most recent first.
Resident-to-resident abuse occurred when one resident with schizoaffective disorder and cognitive impairment struck another resident with severe cognitive impairment on more than one occasion in common areas. Staff observed or were alerted to the assaults, and the aggressor admitted hitting the other resident and threatening others. The injured resident had redness and swelling around the eye after one incident and was later hit again in the back in the TV room.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
A resident did not receive appropriate care for existing pressure ulcers, and necessary interventions to prevent new ulcers were not consistently implemented.
Nurses and nurse aides lacked the appropriate competencies to provide care that maximizes each resident's well-being, resulting in care that did not meet regulatory standards for individualized resident needs.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain the services of a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors during their review of facility practices.
Call Lights Left Out of Reach for Three Residents: The facility failed to keep call lights within reach for three residents with significant care needs, including one resident in a wheelchair and two residents in bed. One resident had moderate cognitive impairment and multiple ADL assistance needs, another had severe cognitive impairment and was incontinent, and a third had intact cognition but required substantial assistance with transfers and hygiene. Observations showed call lights on the floor, under the bed, or attached to the bed while the resident was away from it, and staff interviews confirmed call lights should be within reach, although the DON and Administrator said the facility did not have a call light policy.
A facility failed to ensure residents were routinely offered nourishing snacks outside scheduled meals. Multiple residents said snacks had stopped being passed out after meals, and observations found no snack tray at the nurse’s station on several checks. Staff gave inconsistent accounts of who prepared and distributed snacks, and residents reported that the only snack sometimes available was a PB&J sandwich left at the nurse’s station, with no other options offered.
Food service safety standards were not followed in the kitchen and dining area. A large bag of tater tots and a large bag of steak fries in the freezer were sealed but not labeled with an item description or date, and two beverage dispensers in the dining room also lacked labels and dates. An employee was observed washing dishes while wearing a hair net with holes on his beard, and the DM stated labeling was done by her or staff when she was unavailable.
Pest Control Program Not Maintained: Gnats were observed in multiple resident areas, including bathrooms, rooms, hallways, and on a med cart. Eleven residents reported a gnat problem in their rooms and bathrooms, saying staff had been told and pest control had treated drains without improvement. Staff described informal reporting only, the Maintenance Man said no follow-up plan had been put in place, and the Administrator confirmed there was no pest control policy or procedure in place.
A MA administered Med Pass 2.0 to two residents without measuring the ordered amounts, instead filling unmarked cups and giving 4 ounces to each resident. One resident was ordered 2 ounces and the other 3 ounces. The MA stated she did not realize the supplement needed to be measured, and the DON stated staff were supposed to give all meds, including supplements, as ordered and that graduated cups were available.
Infection control lapses occurred during resident care when an MA checked blood pressure for two residents without disinfecting the BP cuff between uses, and a CNA performed incontinent care for a resident while continuing to use soiled gloves and without washing hands. The residents involved had cognitive impairment and diagnoses including HTN, DM, CVA, and HF, and the DON stated staff must clean equipment between residents and wash hands and change gloves between clean and dirty tasks.
A resident's comprehensive care plan was not reviewed and revised quarterly as required, due to an oversight during a transition between social workers. The resident, with multiple health conditions, had a care plan last revised in early January 2024, but the subsequent quarterly meeting was missed. The facility's policy mandates quarterly reviews in conjunction with MDS assessments.
A resident with Alzheimer's and identified as an elopement risk managed to leave the facility despite wearing a wander guard. The resident was found a quarter of a mile away, and it was unclear how he eloped as the facility's doors were equipped with alarms. The incident occurred during a shift change, and the resident was found safe with no injuries.
The facility failed to document hospice care in a resident's care plan, despite the resident being admitted to hospice. Interviews with staff confirmed that hospice services should be documented, but this was not done, potentially leaving staff without a full picture of the resident's care.
Resident-to-Resident Abuse Not Prevented
Penalty
Summary
The facility failed to ensure two residents were free from abuse when one resident struck the other resident on more than one occasion. One resident had diagnoses including schizoaffective disorder, muscle weakness, end stage renal disease, dysphagia, lack of coordination, abnormal posture, and cognitive communication deficit, and his quarterly MDS reflected a BIMS score of 11 with moderate cognitive impairment. The other resident had diagnoses including dementia, major depressive disorder, fracture of the neck of the right femur, impulse disorders, delusional disorder, acute kidney failure, congestive heart failure, muscle weakness, and weakness, and his quarterly MDS reflected a BIMS score of 4 with severely impaired cognition. Record review showed that on one occasion, staff were alerted that one resident was about to hit the other resident in the hallway. The residents were separated, and the aggressor admitted, "Oh I hit [the other resident], and nothing can be done about it." On another occasion, a resident was observed hitting the other resident in the back twice in the TV room and threatening to hit another resident. The aggressor again acknowledged the behavior, stating, "Yeah, I hit him." The other resident’s record documented redness and swelling under the left eyelid after the earlier incident, and a skull x-ray was obtained for localized swelling of the head. Interviews supported that the aggressor was the resident with schizoaffective disorder and that he believed the other resident was a child molester. The other resident stated he had been hit with a fist in his chest and did not know who hit him, while another resident reported seeing the aggressor hit the other resident twice in the back with no staff present in the TV room at the time. The facility policy stated residents have the right to be free from abuse and that the facility has zero tolerance for abuse, neglect, mistreatment, and misappropriation of resident property.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Provide Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent the development of new ulcers. This deficiency was identified through surveyor observations and review of care practices, which revealed that the necessary interventions to manage existing pressure ulcers and prevent new ones were not consistently implemented for affected residents.
Lack of Staff Competency in Resident Care
Penalty
Summary
Nurses and nurse aides did not demonstrate the necessary competencies to provide care that maximizes each resident's well-being. The deficiency was identified due to a lack of evidence that staff possessed or applied the required skills and knowledge to meet the individualized needs of all residents. This failure resulted in care that did not fully support the highest possible level of well-being for each resident, as required by regulatory standards.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
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 and review of facility practices, which revealed lapses in the protection and management of confidential resident information and incomplete or improperly maintained medical records. The report does not specify the number of residents affected or provide details about their medical history or condition at the time of the deficiency.
Call Lights Left Out of Reach for Three Residents
Penalty
Summary
The facility failed to ensure that residents had their call lights within reach for three residents reviewed for call lights. Resident #10, who had diagnoses including type 2 diabetes, acute kidney failure, dysphagia, and hemiplegia/hemiparesis following cerebral infarction, had a BIMS score of 12 and required assistance with multiple activities of daily living. Her care plan identified her as at risk for falls and included an intervention to ensure her call light was within reach. During observation, she was seen sitting in her wheelchair with her legs elevated on the bed while her call light was on the floor next to the bed, and on another observation she was in her wheelchair away from the bed while the call light remained attached to the bed. Resident #12 had diagnoses including type 2 diabetes with circulatory complications, muscle weakness, lack of coordination, unspecified dementia, major depression, major anxiety, and Alzheimer’s disease. His BIMS score was 3, indicating severe cognitive impairment, and he was documented as always urinary and bowel incontinent. His care plan stated he was at risk for falls and that his call light should be within reach, with prompt response to requests for assistance. During observation, he was lying in bed with the covers on, stated he was okay and did not need anything, and the call light was in the same position as during a prior observation; the resident was not asked about the call light. Resident #36 had diagnoses including hemiplegia affecting the right dominant side, generalized muscle weakness, COPD, vascular dementia, CHF, muscle wasting and atrophy, convulsions, and age-related physical debility. His MDS showed intact cognition with a BIMS score of 14, but he required substantial to maximal assistance for several care tasks and was always urinary and bowel incontinent. His care plan also identified fall risk and included keeping the call light within reach. On observation, he was lying in bed with a blanket on, able to answer close-ended questions in a soft whisper, and the call light was on the floor under the bed; on a later observation it remained in the same position. Staff interviews stated call lights should be within reach, but the DON and Administrator said the facility did not have a call light policy.
Snacks Not Routinely Offered Between Meals
Penalty
Summary
The facility failed to ensure that residents had suitable, nourishing meals and snacks available outside of scheduled meal service times. Surveyors found that snacks were not being prepared, provided, or offered after breakfast, lunch, and dinner, despite the facility’s policy stating that texture-appropriate snacks would be available and provided to all residents and that snacks ordered at 10:00 a.m. and 2:00 p.m. would be labeled and appropriate for residents’ diet orders. During a confidential group meeting, multiple residents stated the facility had stopped offering or passing out snacks about three months earlier and that snacks were not offered after breakfast that morning. Observation of the nurse’s station on multiple occasions showed no snack tray or snacks present, and the nourishment room contained only shakes. Staff interviews were inconsistent about who was responsible for preparing and passing out snacks, with some stating dietary prepared snacks and nursing or aides were responsible for distributing them, while others said aides prepared evening snacks or that the kitchen would only prepare a snack if requested. Resident interviews confirmed the lack of routine snack service. Several residents stated they did not receive or were not offered snacks after meals, that nighttime snacks were inconsistent, and that the only snack sometimes available was a peanut butter and jelly sandwich left at the nurse’s station. One resident stated he never received a snack after breakfast, another stated snacks were never offered during day shifts, and another stated the facility only offered nighttime snacks and no other options. The facility’s grievance logs and resident council minutes contained no complaints about snacks not being provided or offered.
Food Items Not Labeled and Hairnet Not Properly Worn
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in its only kitchen reviewed for food safety. Observation of the side-side refrigerator revealed a large bag of tater tots and a large bag of steak fries that were sealed but had no item description label or distinguishing date. In the dining room, two clear beverage dispensers that appeared to contain iced tea and lemonade were observed on the counter with no item description label or distinguishing date. The facility also failed to ensure dietary staff wore proper hairnets while working in the kitchen. [NAME] A was observed wearing a hair net on his beard with 3 holes while washing dishes, and he stated that everyone is responsible for doing the dishes and cooking. The Dietary Manager stated she is responsible for labeling and that staff do it when she is unavailable, and she said she puts red first-out stickers on items that need to be used before other items. The facility's Food Storage Policy stated frozen foods are to be stored in moisture-proof wrap or containers that are labeled and dated, and the U.S. FDA Food Code 2022 was reviewed regarding labeling, dating, and storage of food and beverages.
Pest Control Program Not Maintained
Penalty
Summary
The facility failed to maintain an effective pest control program. Survey observations found gnats in multiple areas of the building, including resident rooms, bathrooms, a medication cart on Hall 400, a bedside table, hallways, and near a doorway on Hall 500. During a confidential group meeting, eleven residents stated there was a pest control problem with gnats in their bathrooms and rooms, and they reported that staff had been told about it. The residents also stated that pest control had treated the drains, but the gnat problem had not improved. Interviews and record review showed staff did not have a consistent process for documenting or escalating pest sightings. A MA said he would report pests to Maintenance, and an LVN said she would tell the Administrator and Maintenance and write it in the book at the nurse's station, but she had not done so. The Maintenance Man stated pest control came once a month and that no plan had been put in place to follow up on the concerns. The pest control log showed treatment for flies, rodents, bed bugs, and mice, with notes about gnats coming from drains, food and drink attracting pests, and insect lights not working properly. The Administrator stated she was not aware of a pest problem in resident rooms and confirmed there was no policy or procedure for pest control prior to exit.
Unmeasured Nutritional Supplements Given to Two Residents
Penalty
Summary
The facility failed to ensure nutritional supplements were administered in the amounts ordered by the physician for two residents. During observation of a medication pass, MA B gave Resident #21 Med Pass 2.0 without measuring the supplement and poured the entire unmarked glass full into the resident’s cup. The observation showed 4 ounces in the cup, even though the physician order required 60 ml (2 ounces). Resident #21’s current physician orders dated 08/05/2025 directed house supplement (Med pass 2.0) three times daily at 60 ml, and the MAR showed the supplement was given at 3:00 p.m. A similar event was observed for Resident #26, when MA B administered Med Pass 2.0 without measuring the ordered amount and again poured the entire unmarked glass full. The observation showed 4 ounces in the cup, although the physician order required 90 ml (3 ounces). Resident #26’s current physician orders dated 08/05/2025 directed house supplement (Med pass 2.0) three times daily at 90 ml, and the MAR showed the supplement was given at 3:00 p.m. During interview, MA B stated she did not realize the supplement needed to be measured and that she just filled the cup and gave it to the residents. The DON stated staff were supposed to administer all medications, including supplements, as ordered and that graduated cups were available to measure supplement or water.
Infection Control Lapses During Resident Care
Penalty
Summary
The facility failed to maintain its Infection Prevention and Control Program when staff did not follow infection control practices during resident care. During medication pass, MA B checked blood pressure for Resident #20 and Resident #31 without disinfecting the blood pressure cuff between uses. The report states that MA B used hand sanitizer before collecting supplies and again after leaving the room, but did not clean the machine prior to or after use on either resident. Resident #20’s quarterly MDS reflected diagnoses of hypertension, diabetes, and heart failure, with a BIMs score of 11 indicating moderate cognitive impairment and need for assistance with activities of daily living. Resident #31’s quarterly MDS reflected diagnoses of hypertension and cerebral accident, with a BIMs score of 9 indicating moderate cognitive impairment and need for assistance with activities of daily living. Physician orders for both residents included blood pressure monitoring every shift, and for Resident #31, blood pressure checks were ordered prior to giving blood pressure medications. During incontinent care for Resident #35, CNA D did not use hand gel before entering the room, did not wash hands before putting on gloves, and continued care with soiled gloves while cleaning the resident’s genital and rectal areas. CNA D also used the soiled gloves to reposition the resident and wipe the resident’s mouth, and removed the gloves in the room without washing hands. Resident #35’s quarterly MDS reflected hypertension and heart failure, with a BIMs score of 11 indicating moderate cognitive impairment and need for assistance with activities of daily living.
Missed Quarterly Care Plan Review for Resident
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive assessment and quarterly review assessments. This deficiency was identified for a resident who had been admitted to the facility with multiple diagnoses, including end-stage renal disease, a history of an open wound on the left foot, type 2 diabetes with a foot ulcer, and peripheral vascular disease. The resident's care plan, last revised in early January 2024, indicated resistance to care, medication, food, and therapy, with interventions to encourage participation and provide clear explanations of care activities. The last care plan conference for the resident was held in June 2024, and the subsequent quarterly care plan meeting was missed due to an oversight during a transition between social workers. The social worker acknowledged the oversight and stated that care plan meetings should coincide with the MDS assessments. The administrator confirmed that the social worker was responsible for ensuring quarterly care plan meetings and attributed the missed meeting to the transition period. The facility's policy requires the interdisciplinary team to review and update care plans quarterly, in conjunction with the required MDS assessment.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident identified as being at risk for elopement. The resident, who was admitted for respite care, was diagnosed with Alzheimer's disease, dementia, glaucoma, and conductive hearing loss. Despite wearing a wander guard, the resident managed to elope from the facility and was found walking on a sidewalk a quarter of a mile away. This incident occurred during a shift change, and it was noted that the resident did not have the wander guard on when found. The resident's care plan identified him as an elopement risk due to his Alzheimer's diagnosis, with interventions including distraction through activities and monitoring of the wander guard every shift. However, during the incident, staff were unable to locate the resident during their rounds, and an elopement plan of action was initiated. The facility conducted a search, and the resident was eventually found safe by emergency services, with no injuries or distress noted. Interviews with staff revealed that the doors were equipped with alarms that should sound if opened without a code, but it was unclear how the resident managed to leave the facility. The facility's policy on wanderer management and elopement protocol was in place, but the incident highlighted a lapse in its implementation, as the resident was able to elope despite being identified as a high risk for wandering.
Failure to Document Hospice Care in Resident's Care Plan
Penalty
Summary
The facility failed to obtain the most recent hospice plan of care specific to each patient's needs for one of the three residents reviewed for hospice services. Specifically, the facility did not ensure that Resident #1's hospice care was care planned. Resident #1, a 73-year-old female with diagnoses including endometrial cancer and chronic obstructive pulmonary disease, was admitted to hospice on January 22, 2024. However, her comprehensive care plan dated November 21, 2023, did not reflect any hospice care plan. This discrepancy was confirmed through interviews with the Director of Nursing (DON), the MDS coordinator, and the administrator, all of whom acknowledged that hospice services should be documented in the care plan but were not in this case. The MDS coordinator stated that the risk of not updating the care plan would be that staff would not have a full picture of the resident's care. The administrator also confirmed that the interdisciplinary team (IDT) discusses residents' needs daily and that hospice care should be documented in the care plan. Despite the administrator's assertion that there was no risk to the resident due to hospice being in the building frequently and the existence of a hospice binder, the facility's policy on charting and documentation requires that all services provided to the resident be documented in the medical record to facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.
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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 Mesquite
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Edgewood Rehabilitation And Care Center | 0.9 mi | ★★★★★ | 2 | 0 |
| Mesquite Tree Nursing Center | 1.5 mi | ★★★★★ | 12 | 0 |
| Willowbend Nursing And Rehabilitation Center | 1.6 mi | ★★★★★ | 19 | 0 |
| Cheyenne Medical Lodge | 2.2 mi | ★★★★★ | 1 | 0 |
| Palomino Place | 2.9 mi | ★★★★★ | 13 | 1 |
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