Mesquite Tree Nursing Center

In the surveyor’s words

From the most serious findings on record at Mesquite Tree Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Aug 27, 2023

  Based on interview and record review the facility failed to ensure resident was free of any significant medication errors for 1 of 6 residents (Resident #1) reviewed for significant medication errors. The facility failed to ensure Resident #1 was free of any significant medication errors by failing to ensure a resident received the correct prescribed intravenous (IV) medication, which resulted in the resident being given an IV medication that she had a known allergy to. This failure resulted in a PNC IJ (Past Non-Compliance Immediate Jeopardy), the IJ (Immediate Jeopardy) started on 08/24/2023 and ended on 08/26/2023. The facility had corrected the IJ (Immediate Jeopardy) prior to entry for abbreviated survey. […]

• Immediate jeopardy, isolatedF686May 4, 2023

  Based on interview, and record review the facility failed to ensure one (Resident #1) of three residents reviewed for pressure ulcers received treatment and care in accordance with professional standards of practice in that: 1. Resident #1 admitted with a pressure ulcer on 12/02/22 and the facility failed to perform and document a wound assessment, notify the physician, and obtain wound care orders until six days later on 12/08/22. 2. The facility failed to ensure Resident #1 was provided with wound care to promote healing until six days after admission on 12/08/22 when he was assessed by the Wound Care Physician (WCP) with an unstageable deep tissue injury to the sacrum. […]

• No harm, potential for more than minimal, widespreadF812Jun 10, 2021

  Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of one kitchen. 1. The facility failed to date food items in the dry storage area. 2. The facility failed to ensure Dietary Cook F, Dietary Cook H and Dietary Aide G wore effective hair restraints while in the kitchen. 3. The facility failed to ensure the dish machine chlorine test strips worked to ensure chemical sanitization levels. These failures could place residents at risk for food-borne illness and food contamination. Findings include: 1. […]

• No harm, potential for more than minimal, patternF800Jun 24, 2026

  Based on observation, interview and record review, the facility failed to provide each resident with nourishing, palatable, well-balanced diet that meets the resident's nutritional needs for 2 of 5 residents (Resident #1 and Resident #2) reviewed for dietary needs.The facility's kitchen failed to prepare and serve 3 ounces of pork loin as stated on resident meal tickets on 06/24/2026.This failure places residents at risk of not meeting their daily nutritional needs and could result in weight loss or decline in overall quality of health. Findings included:Record review of Resident #1's face sheet, dated 06/24/2026, revealed a [AGE] year-old male, admitted on [DATE] with a primary diagnosis of cerebrovascular disease (condition that impacts blood vessels in the brain). […]

• No harm, potential for more than minimal, patternF812Jun 24, 2026

  Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen.The facility failed to ensure a bag of dry rolled oats were not sitting on the floor in the kitchen preparation area.The facility failed to ensure raw meat was being thawed properly.The facility failed to ensure food items were not in the same sink compartment as used dishes.These failures could place residents at risk for foodborne illness and foodborne intoxication.Findings included:Observation on 06/24/2026 at 12:19 PM of the facility's kitchen revealed a 50 lb bag of rolled oats sitting on the kitchen floor leaning up against a food preparation table.Observation on 06/24/2026 at… […]