Christian Care Communities and Services Mesquite

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 (Resident #1) of 5 residents reviewed for reasonable accommodations.The facility failed to provide a bed extension to accommodate resident preferences.This failure could place residents at risk of not being able to meet their needs.Findings included:During a record review of Resident #1's face sheet, dated 11/10/25, revealed an [AGE] year-old man admitted on [DATE] with diagnoses of encephalopathy (disturbance of brain function), type 2 diabetes mellitus without complications (a condition where high blood sugar levels occur because the body's cells don't respond properly to insulin, but without the development of other health problems like nerve damage or heart disease), vascular dementia (a decline…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure that medications were secure and inaccessible to unauthorized staff and residents for two (one medication cart for Hall 200 and one medication cart for Hall Burgundy on the rehab unit) of five medication carts reviewed for medication storage. 1. The facility failed to ensure medication supplies were all stored in locked compartments and permit only authorized personnel to have keys, when CMA A's one medication cart for Hall 200 were left unlocked and unattended by CMA A. 2. The facility failed to ensure medication supplies were all stored in locked compartments and permit only authorized personnel to have keys when LVN B's one medication cart for Hall Burgundy for Rehab and was left unlocked and unattended by LVN B. This failure could result in resident access and ingestion of medications leading to a risk for harm and possible drug diversion.Findings included: An observation on 08/16/2025 at 9:14 a.m. revealed MA A's one…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete; accurately documented; readily accessible; and systematically organized for 1 (Resident #1) of 2 for accuracy of records. The facility failed to accurately document an incident of elopement in progress notes that occurred r/t Resident #1. The failure can affect residents by putting them at risk of preventing further elopements r/t the lack of accurate documentation of incident. Findings included: Record review of Resident #1's face sheet dated 08/12/2025 revealed he was a [AGE] year-old male admitted to the facility on [DATE]. Resident discharged to another from facility on 05/03/2025. Admitting diagnosis was Metabolic Encephalopathy (a condition where brain's dysfunction occurs due to issues with the body's metabolism, which can manifest confusion, impaired thinking, or even coma); Cerebral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services (including procedures that ensured drugs and biologicals were accurately acquired, received, dispensed, and administered) to meet the needs of each resident for one (2100 hall medication room) of two medication rooms reviewed for pharmacy services. The facility failed to ensure expired medication administration supplies were removed from the east side medication room. These failures could place residents at risk for infection and having possible adverse effects. Findings included: In an observation and interview on [DATE] at 9:37 a.m., expired supplies were found stored on shelves in the 2100 hall medication room. Expired supplies observed included one 100 count box of 5mL 22gauge x 1.5inch syringes with an expiration date of [DATE] and one 100 count box of 3mL 23gauge x 1inch syringes with an expiration date of [DATE]. RN A was present during the observation and stated the syringes were expired, and the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. 1. The facility failed to remove molded fruits. 2. The facility failed to ensure dented cans were placed in a separate storage area. These failures could place residents at risk for food-borne illness and cross contamination. Findings Include: Observation of walk-in refrigerator on 03/11/2025 at 9:27 a.m., revealed the following: -1 16oz bag of grapes dated 03/07/2025 contained molded grapes. -1 16oz container of strawberries dated 03/07/2025 contained molded strawberries. -2 6oz containers of raspberries dated 02/28/2025 contained molded raspberries. Observation of dry storage on 03/11/2025 at 9:35 a.m., revealed the following: -1 3lbs can of cream of chicken dated 02/11/2027 was dented twice on the top left. -1 6lbs can of tapioca pudding dated 02/05/2028 was dented on top right. In an interview with [NAME] B on 03/11/2025 at 11:25 a.m., she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews the facility failed to ensure professional staff were licensed, certified or registered in accordance with applicable state laws for one (ADON) of four licensed nursing staff reviewed for staff qualifications. The facility failed to ensure the ADON's Nursing license was not expired. The past noncompliance began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk for receiving nursing services by an unlicensed nurse. Findings included: During an interview, on [DATE] at 2:30 pm, the HR Manager stated the staff licenses were checked upon hire. She stated when staff came in for background checks, all the other checks were completed. She stated the facility noted the expiration date of the license or certification and let the staff know when the license would expire, and at that point it was the employees' responsibility. She stated effective [DATE] the responsibility was given to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to immediately report an allegation of abuse to HHSC for one (Resident #3) of five residents reviewed for abuse. The facility failed to report an allegation of abuse as required when Resident #3's family member reported to the facility that Resident #3 had been abused by PT B. This failure could place residents at risk for unreported allegations of abuse. Findings included: Record review of the Minimum Data Set (MDS) dated [DATE] indicated Resident #3 was admitted on [DATE], was a [AGE] year old female, and her diagnoses in part included Hypertension (elevated blood pressure), Obstructive Uropathy (occurs when urine cannot drain through the urinary tract), Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), Asthma (a chronic disease that affects the airways of the lungs), Open Wound, Fibromyalgia (pain in muscle and joints throughout the body), Muscle Weakness, Other Reduced Mobility, and Morbid Obesity. The MDS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure all assistive devices were maintained and free of hazards for five (Residents #10, #12, #53, #69, and #183) of eighteen residents reviewed for essential equipment. The facility failed to properly maintain wheelchairs for Residents #10, #12, #53, #69, and #183. This failure could place residents at risk for equipment that is in unsafe operating condition, which could cause injury. Findings included: Review of Resident #10's quarterly MDS assessment , dated 1/16/24, reflected she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Dementia (confusion and forgetfulness), generalized weakness, and heart failure (heart weakness). Resident #10 had a BIMS score of 99 indicating she was severely cognitively impaired and unable to make decisions for herself. Further review of section GG revealed she was dependent for mobility use of a wheelchair. Review of the Resident #10's plan of care dated 01/16/24 with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food storage, labeling, dating, and kitchen sanitation. 1. The facility failed to ensure food in the facility's refrigerator, was labeled and dated according to guidelines. 2. The facility failed to ensure food in the facility's refrigerator, was not exposed from air-borne contaminants. 3. The facility failed to dispose of expired foods items in the refrigerator and freezer. These failures could place residents who receive food prepared in the facility's kitchen at an increased risk of exposure to food-borne illnesses. Findings included: Observation of the Refrigerator on 2/6/24 at 9:20 AM revealed the following: On back wall, bottom row had peeled potatoes inside a container filled with water, no date. On back wall, top shelf had brown liquid substance in a pitcher covered, no date. On back wall, middle shelf had opened salad mix, no date.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Residents #182) of eight residents reviewed for infection control. The facility failed to ensure Occupational Therapist G properly donned and doffed PPE by putting on an isolation gown before entering Resident #182's contact isolation room; additionally, when Occupational Therapist G left the resident's room, she took her gown off in the hallway then went back into Resident 182's room to dispose of the gown. Then afterwards she went to two other resident's rooms. This failure could place residents at risk of cross contamination of highly infectious diseases, which could lead to the residents experiencing respiratory distress, fevers, muscle aches, vomiting and diarrhea and resulting in health decline and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to inform each resident periodically during the resident's stay, of services available in the facility and charges for those services, including services not covered under Medicare/Medicaid and must inform the resident in writing at least 60 days prior to implemention of the change for one (Resident #185) of eight residents reviewed for [NAME] Services. The facility failed to develop, implement, and practice appropriate billing practices, subsequently Resident #185's room and board fees increased to $225.00 per day after his managed care insurance coverage ended on 12/24/22. The facility failed to notify Resident #185's RP about the increase in the resident's room and board fees on 12/24/22 to $225.00 per day; inadvertently, the facility waited seven months after the resident admitted then added the additional accumulated charges to his July 2023 and August 2023 billing statements. These failures could place residents at risk of an accelerated depletion…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.