Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Highland Manor Of Mesquite Rehabilitation Llc during CMS and state inspections, most recent first.
Failure to Provide Advance Directive Education: The facility did not provide written information or education about advance directives to four cognitively intact residents who had POLST forms and admission records noting DNR or comfort-focused treatment. Records for the residents showed diagnoses including CHF, COPD, respiratory failure, dementia, and CKD, but no documentation of advance directive education was found. Two residents stated the facility had not asked about or offered advance directive information, and the RVPO confirmed the facility could not locate any documentation of such education.
Dirty oxygen concentrator filters were observed for multiple residents receiving O2 therapy. Residents with diagnoses including COPD, hypoxemia, and respiratory failure were seen on nasal cannula while the concentrator filters had heavy dust or lint buildup. An LPN later removed one filter and confirmed it was very dirty, and an RN also acknowledged another filter was dirty and needed cleaning.
Laundry staff were not aware of the PPE available for sorting dirty laundry. During observation, no face shields or goggles were seen in the sorting area, and a laundry aide stated her apron was at home, the gloves were on the wall, and she used reading glasses instead of eye protection. The DON later stated the expectation was that aprons not be taken home and that face shields be available for eye protection, while the facility policy required laundry staff to handle linens to prevent spread of infection.
The facility did not maintain menu spreadsheets for weekly menus, including portion sizes and therapeutic diets, impacting residents' nutritional needs. Menus were neither updated nor reviewed by a dietitian, and were not followed as per facility policy. Observations revealed that serving utensils were used without reference to menu spreadsheets, leading to meals being served without consideration of specific dietary requirements. Residents with specific dietary needs, such as those with Alzheimer's, respiratory failure, dysphagia, diabetes mellitus, and vegetarian preferences, received meals that did not align with their prescribed diets. The Food Service Manager cited a transition to a new menu program and lack of training, while the Registered Dietitian noted the need for menu extensions and power foods for high calorie and protein diets.
The facility did not follow proper procedures for handwashing, cooling leftovers, and dating leftovers, affecting all residents receiving meals from the kitchen. Observations showed issues with food temperature maintenance, handwashing practices, and food item labeling. Cook1 held puree foods below the required temperature, and the FSM admitted to improper reheating procedures. Leftover Swedish meatballs and butternut squash were not cooled promptly, and undated omelets were found in the refrigerator. Both the FSM and Cook2 did not follow correct handwashing protocols, indicating a systemic issue in staff hygiene. The facility's policies lacked clear instructions on food temperature maintenance, handwashing, and food labeling. Staff showed a lack of awareness regarding proper food handling, such as cooling hot foods promptly and using soap during handwashing, posing a risk to resident health and safety.
The facility reported incidents involving six residents who experienced verbal and physical abuse. A CNA verbally abused two residents, calling one 'stupid,' which caused emotional distress. This behavior led to the CNA's termination. Additionally, two residents were involved in a physical altercation following aggressive comments, resulting in staff intervention. Another incident involved two residents where one displayed physical aggression, causing injuries. The aggressive resident was relocated and received 1:1 supervision until discharge. These events highlight the need for vigilance in preventing abuse among residents and staff.
The facility failed to complete a background check for a CNA before hire, allowing them to work multiple shifts with a provisional status. This was against the facility's policy and had the potential to negatively impact all residents.
The facility failed to thoroughly investigate an allegation of staff-to-resident verbal abuse involving two residents. The investigation lacked interviews with all potential witnesses and detailed documentation, placing the residents at risk of increased mental health issues and a diminished quality of life.
The facility failed to ensure that the Food Service Supervisor had completed a required course in food safety and management. The supervisor was hired with relevant experience but provided a certificate with an issue date after the hire date, indicating the course was retaken. This deficiency had the potential to affect all residents receiving meals from the facility's kitchen.
Failure to Provide Advance Directive Education
Penalty
Summary
The facility failed to ensure four of five residents reviewed were provided written information or education about advance directives and the right to formulate an advance directive. Resident 1 was admitted with diagnoses including transient cerebral ischemic attack, COPD, asthma, altered mental status, sleep disorder, and Alzheimer's dementia; the admission record listed a DNR/Allow Natural Death, comfort-focused treatment, no IV fluids, and no artificial nutrition or feeding tube. Resident 1's quarterly MDS showed a BIMS score indicating cognitive intactness, but the EMR contained a completed POLST form and the admission packet did not show any education regarding an advance directive. Resident 12 was admitted with diagnoses including CHF, COPD, type 2 diabetes, acute respiratory failure, and chronic kidney disease; the admission record listed DNR, selective treatment, and an artificial nutrition/feeding tube trial, and the admission MDS showed a BIMS score of 14. Resident 20 was admitted with acute and chronic respiratory failure, UTI, metabolic encephalopathy, hypertensive heart disease, dementia, and heart failure; the admission record listed DNR/Allow Natural Death, comfort-focused treatment, and no artificial nutrition or feeding tube, and the admission MDS showed a BIMS score of 14. Resident 79 was admitted with COPD exacerbation, acute respiratory failure with hypoxia and hypercapnia, pulmonary hypertension due to lung disease and hypoxia, and heart failure; the admission record listed DNR, comfort-focused treatment, no artificial nutrition or feeding tube, and no IV fluids, and the admission MDS showed a BIMS score of 15. For Residents 12, 20, and 79, the EMR showed POLST forms but no advance directives or documentation of education regarding advance directives. On interview, Resident 20 stated the facility had not asked about advance directives and had not provided education, and Resident 79 stated nobody had ever offered. The Regional Vice President of Operations stated the facility could not find anything regarding advance directive education for the four residents and confirmed there was no documentation of resident education regarding advance directives. The facility policy required the facility to determine on admission whether a resident had executed an advance directive and, if not, to determine whether the resident wanted to formulate one and provide information about the right to refuse treatment and formulate an advance directive.
Dirty oxygen concentrator filters observed for multiple residents
Penalty
Summary
The facility failed to ensure oxygen concentrator filters were kept free of dust and heavy lint buildup for three sampled residents receiving oxygen therapy. Residents R62, R5, and R79 were each observed using oxygen via nasal cannula while the exterior or cabinet filters on their oxygen concentrators were visibly dirty, with thick buildup of white lint or significant dust/lint noted during repeated observations by surveyors. R62 had diagnoses including bradycardia, hypoxemia, and atrial fibrillation, and had an order for oxygen at 2 L via nasal cannula to maintain oxygen saturation greater than 90% as needed for shortness of breath related to hypoxemia. On multiple observations, R62 was lying in bed wearing oxygen while the concentrator’s black side filter remained very dirty and full of white lint. R62 stated they had not seen staff change or clean the filter, and an LPN later removed the filter and confirmed it was very dirty with heavy lint buildup and said she was not aware of when it was last cleaned. R5 had diagnoses including COPD and chronic cough and had an order for oxygen at 2 L/min via nasal cannula, with titration to keep oxygen saturations above 92% as needed for shortness of breath related to COPD. The concentrator filter was observed repeatedly to be very dirty and full of white lint while R5 was on oxygen, and R5 stated they had not seen staff clean or change the filter. An LPN later removed the filter and found it clean after replacing it, stating she had just changed it because it needed cleaning. R79, who had diagnoses including COPD with exacerbation, acute respiratory failure with hypoxia and hypercapnia, pulmonary hypertension due to lung disease with hypoxia, and heart failure, was observed receiving oxygen at 3 LPM with a significant buildup of dust/lint on the concentrator’s exterior intake filter. An RN confirmed the filter was dirty and needed cleaning. The maintenance director and other facility staff described a monthly filter-cleaning process, but the observations showed the filters for these residents remained dirty during the survey period.
Laundry PPE Not Available or Known During Dirty Linen Sorting
Penalty
Summary
The facility failed to ensure that laundry staff were aware of the PPE available for use while sorting dirty laundry. During an observation of the laundry area on 04/10/2026 at 4:00 PM, no face shields or goggles were observed anywhere in the vicinity of the sorting area. A laundry aide stated that dirty clothes were brought in a barrel, removed, and placed into whites or colored for washing. When asked about aprons, gloves, and eye protection, the aide stated she had an apron but it was at home, said the gloves were on the wall, and stated she wore her reading glasses instead of eye protection. During an interview with the DON on 04/10/2026 at 4:15 PM, the laundry aide again stated the apron was at home because it had been taken home to wash and forgotten there. The aide did not know where the eye protection was and stated she had never had any. The DON stated the expectation was not to take aprons home and that face shields should be available for eye protection. The facility policy titled Infection Prevention and Control Program stated that laundry and direct care staff shall handle, store, process, and transport linens to prevent spread of infection.
Menu Planning and Dietary Adherence Deficiencies
Penalty
Summary
The facility failed to have menu spreadsheets for the weekly menus that included portion sizes and regular and therapeutic diets for all residents, impacting the nutritional needs of residents. Menus were not updated, reviewed by a dietician, or followed as required by the facility's policy. The deficiency affected all residents who received meals prepared in the facility's kitchen. Observation of meal services on multiple occasions revealed that serving utensils were used without reference to menu spreadsheets, and residents were served meals without consideration of their specific dietary requirements. In the case of Resident 29 (R29), who was on a Regular High Calorie/High Protein diet with a mechanical soft texture, the resident was served meals that did not align with the prescribed diet. Despite the resident's specific dietary needs due to diagnoses of Alzheimer's disease, respiratory failure, and dysphagia, the facility failed to provide appropriate meals. Similarly, for Resident 16 (R16) on a Regular Puree diet due to dysphagia and dementia, the meals served did not match the prescribed diet, potentially compromising the resident's nutritional intake and well-being. Resident 34 (R34), with a diagnosis of diabetes mellitus and vegetarian preferences, did not receive appropriate vegetarian options and lacked protein in the meal served, highlighting a failure to meet the resident's dietary requirements. The Food Service Manager (FSM) and Registered Dietitian (RD) were unaware of the lack of menu spreadsheets and deviations from prescribed diets for residents. The FSM mentioned a transition to a new menu program and lack of training, while the RD highlighted the need for menu extensions and the utilization of power foods for high calorie and protein diets. The deficiency in menu planning and adherence to dietary requirements was evident through the observations of meal services and the discrepancies between prescribed diets and actual meals served to residents, indicating a systemic issue in ensuring residents' nutritional needs were met appropriately.
Deficiencies in Handwashing, Food Cooling, and Labeling Procedures
Penalty
Summary
The facility failed to adhere to proper procedures for handwashing, cooling leftovers, and dating leftovers, potentially impacting all residents who received meals prepared in the facility's kitchen. Observations revealed discrepancies in food temperature maintenance, handwashing practices, and labeling of food items. Cook1 was found holding puree foods below the required temperature, while the FSM acknowledged the lack of proper reheating procedures. Leftover Swedish meatballs and butternut squash were not cooled promptly as per guidelines, and omelets were left undated in the refrigerator. Additionally, both the FSM and Cook2 were observed not following correct handwashing protocols, highlighting a systemic issue in staff hygiene practices. The deficiency in food safety protocols was further compounded by inadequate staff training and non-compliance with established policies. The facility's policies lacked clear instructions on food temperature maintenance, handwashing procedures, and food labeling requirements. Staff members demonstrated a lack of awareness regarding proper food handling practices, such as cooling hot foods promptly and using soap during handwashing. These deficiencies in training and adherence to policies posed a significant risk to the health and safety of residents who relied on the facility for their meals.
Incidents of Verbal and Physical Abuse Among Residents and Staff
Penalty
Summary
The facility failed to ensure that six residents (R40, R60, R5, R57, R19, and R130) were free from verbal and physical abuse. Resident 40 (R40) and Resident 60 (R60) were subjected to verbal abuse by a Certified Nurse Assistant (CNA) who called R40 "stupid," leading to emotional distress for the residents. The investigation revealed that CNA1's behavior escalated, resulting in the termination of their employment. Resident 5 (R5) and Resident 57 (R57) were involved in a physical altercation where R5 made aggressive comments towards R57, leading to physical violence between the two residents. Both residents were separated and redirected by staff following the incident. Additionally, Resident 19 (R19) and Resident 130 (R130) were involved in a physical altercation where R130 threw punches at R19, resulting in injuries to both residents. R130 displayed physical aggression towards R19, leading to scratches and abrasions on R130's body. The investigation documented that R130 was relocated to another hall and received 1:1 supervision until discharge. The report highlighted the need for the facility to ensure the safety and well-being of all residents by preventing verbal and physical abuse among residents and staff.
Failure to Complete Background Check for CNA Before Hire
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA3) had a completed background check prior to hire, as required by their policy on Abuse Prohibition and Reporting. CNA3 was hired on January 15, 2024, but their fingerprints were not completed and re-mailed until February 20, 2024. Despite the incomplete background check, CNA3 worked multiple shifts from January 28, 2024, to April 22, 2024. The facility's records showed that the background check was still in process, and CNA3's employment status was provisional. The Human Resources Manager confirmed that the fingerprints had to be re-sent due to an error, and the results had not yet been received. The Administrator acknowledged that the state was behind on processing fingerprints and that staff must be let go if their background check cannot be appealed. The facility's failure to complete the background check for CNA3 before allowing them to work had the potential to negatively impact all residents. The facility's policy required screening of potential employees, including healthcare workers' background checks and screening through the Office of Inspector General (OIG) Exclusion database. However, CNA3 was allowed to work without a completed background check, which was against the facility's policy and could have put residents at risk. The deficiency was identified through a review of CNA3's employee file, facility policies, and interviews with the Human Resources Manager and Administrator.
Incomplete Investigation of Verbal Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident verbal abuse involving two residents. Resident 40, who has a history of stroke with left-sided paralysis, bipolar disorder, and affective mood disorder, reported that a Certified Nurse Aide (CNA) called them 'stupid' while assisting them in the bathroom. Resident 60, who has Parkinson's disease, bipolar disorder, and PTSD, overheard the incident and reported it to a Registered Nurse. The facility's investigation was incomplete, as it did not include interviews with all potential witnesses or detailed documentation of the interviews that were conducted. The Facility Investigation report only included written statements from two staff members and lacked documentation of interviews with other staff or residents who may have witnessed the incident. The Social Services Director (SSD) admitted to speaking with two other residents but failed to document their names or responses. The Administrator acknowledged that the investigation was not complete after reviewing the report. This failure to conduct a thorough investigation placed the residents at risk of increased mental health issues and a diminished quality of life.
Failure to Ensure Food Service Supervisor Completed Required Course
Penalty
Summary
The facility failed to ensure that the Food Service Supervisor had completed a course in food safety and management, as required by the job description. The Food Service Supervisor was hired on 12/12/23 and had two or more years of experience as a kitchen supervisor in a healthcare setting. However, the certificate of completion for the Certified Food Protection Manager course had an issue date of 04/24/24, which was after the hire date. During interviews, the Food Service Supervisor confirmed that they had retaken the course because they could not find the certificate for the previously taken course. This deficiency had the potential to affect all residents who received meals prepared in the facility's kitchen.
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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) |
|---|---|---|---|---|
| Southern Utah Veterans Home - Ivins | 32.9 mi | — | 0 | 0 |
| Seasons Healthcare And Rehabilitation | 33.9 mi | — | 0 | 0 |
| Advanced Health Care Of St. George | 34.8 mi | — | 0 | 0 |
| Bella Terra St George | 34.9 mi | — | 4 | 0 |
| St. George Rehabilitation | 35 mi | — | 0 | 0 |
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