Highland Manor of Mesquite Rehabilitation LLC

In the surveyor’s words

From the most serious findings on record at Highland Manor of Mesquite Rehabilitation LLC, in the surveyor’s own words.

• Actual harm, isolatedF600May 2, 2025

  Based on interview, record review, and document review the facility failed to ensure a resident was free from neglect for an unsampled resident (Resident 182). The deficient practice resulted in a superficial burn injury. Findings include: Resident 182 (R182) was admitted on [DATE] with diagnoses including fracture of shaft of left femur and abnormalities of gait and mobility. The facility reported to the state agency a Certified Nursing Assistant (CNA) had reported R182 was having back pain on 12/26/2024 at 5:00 PM. The CNA notified the nurse and Director of Nursing (DON). R182 was assessed and an abrasion with redness on the mid back area was identified. R182 reported having a heating pad on earlier in the day while in therapy. […]

• Actual harm, isolatedF689Mar 9, 2023

  Based on observation, interview, record review, and facility policy review, the facility failed to ensure one (Resident (R)26) of three residents reviewed for falls received services to prevent additional falls. R26 sustained multiple falls, including on 06/01/22, 07/08/22, and 08/15/22. The facility failed to conduct a thorough investigation and root cause analysis to identify possible contributing factors, the reason for the fall, and the need for new/different interventions to prevent further falls. After this failure, R26 sustained another fall, on 11/30/22, resulting in a hip fracture. Findings include: Review of R26's face sheet revealed R26 was admitted to the facility on [DATE]. Diagnoses included restlessness and agitation, cognitive communication deficit, and Alzheimer's Disease. […]

• No harm, potential for more than minimal, widespreadF803Apr 25, 2024

  Based on observation, interview, record review, and policy review, the facility failed to have menu spreadsheets for the weekly menus that included portion sizes and regular and therapeutic diets for all residents and three of eight residents R16, R29, and R34) who were reviewed for menus. This deficient practice affected all residents who received meals prepared in the facility's only kitchen. Findings include: Review of the facility policy titled Menu Planning, revised 09/10, revealed: Purpose: To provide a variety of meals that are well balanced, palatable, attractive, satisfying and meet the recommended daily allowances. 2. […]

• No harm, potential for more than minimal, widespreadF812Apr 25, 2024

  Based on observation, interview and policy review, the facility failed to use proper procedures for handwashing, cooling leftovers, and dating leftovers. This deficient practice had the potential to affect all residents who received meals prepared in the facility's kitchen. Findings include: Facility policy titled Use of Steam Table in Dining Area, dated 2020, revealed no instructions for holding temperature for hot and cold foods. Review of the United States Federal Food & Drug Food Code 2022: http://www.fda.gov/Food/GuidanceRegulation/RetailFoodProtection/FoodCode/, revealed: 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. […]

• No harm, potential for more than minimal, patternF578Apr 10, 2026

  Based on interviews, record review, and facility policy review, the facility failed to ensure four of five residents reviewed (Resident (R) 1, R12, R20, and R79) were provided with written information or education regarding advance directives and the right to formulate an advance directive to ensure their desired level of medical care was known in the event they were unable to direct care on their own. This failure had the potential to affect the ability of cognitively intact residents to direct their care.Findings include:R1 was admitted on [DATE] with diagnoses including transient cerebral ischemic attack, chronic obstructive pulmonary disease (COPD), asthma, altered mental status, sleep disorder, and Alzheimer's dementia. […]