Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Mesquite Post Acute Care during CMS and state inspections, most recent first.
Three residents with cognitive and behavioral health diagnoses were involved in separate incidents of physical aggression toward others. Although staff responded to each event with immediate interventions such as monitoring and separation, the care plans for these residents were not updated to reflect the new behaviors or to include specific, measurable interventions. Facility staff and leadership acknowledged that while the incidents were discussed in meetings, the care plans were not revised to address the aggressive behaviors.
The facility failed to inform 12 of 20 residents about their rights and procedures for filing grievances. Residents were unaware of how to file grievances, lacked access to forms, and did not know about their right to a written decision. Observations showed inadequate posting of grievance procedures and inaccessible grievance forms. The Administrator acknowledged the system's shortcomings and the lack of resident education on the grievance process.
The facility failed to log controlled drugs awaiting disposal, leading to inaccuracies in drug reconciliation. Unlogged medications were found in storage, and the DON was unaware of the logging requirement. Additionally, expired medications were found in a medication cart, indicating lapses in checks. Facility policies require logging and secure storage of medications, but these were not followed, risking potential negative outcomes.
A resident's OOH-DNR form was incomplete, lacking necessary witness and notary signatures, which could invalidate the document. The facility lacked a social worker to complete these forms, and the DON was not trained in their completion. This oversight could lead to the resident's end-of-life wishes not being honored during emergencies.
The facility failed to seal foods stored in the refrigerator, as observed with slaw, lunch meat, and sliced cheese in unsealed plastic bags. Interviews with the DM and ADM confirmed that all food should be sealed, and staff had been trained accordingly. The facility's policy requires daily checks of refrigerators, which were not effectively implemented, leading to potential risks of food contamination.
A LTC facility failed to maintain an effective infection control program, as evidenced by two incidents. An LVN did not sanitize his hands between glove changes during wound care for a resident, risking cross-contamination. Additionally, a CNA did not wear a gown while providing care to a resident on Enhanced Barrier Precautions, contrary to facility policy. Both staff members had received recent training on infection control but did not adhere to protocols.
The facility failed to provide the required minimum of 80 square feet per resident in four semi-private rooms, despite having a waiver for these room size requirements. The rooms were unoccupied at the time of the survey due to ongoing renovations, and the ADM expressed the intention to continue the waiver. No policy was provided regarding room size compliance.
A resident with a history of behavioral issues was slapped on the arm by a CNA after the resident spat at her. The incident was witnessed by a social worker who intervened and reported it to the administration. The CNA admitted to the action, citing it as a knee-jerk reaction, despite being aware of the facility's abuse prevention policies.
The facility failed to maintain an infection control program, leading to potential infection risks for two residents. An LPN did not change gloves or wash hands properly during wound care, and interviews confirmed non-compliance with handwashing policies.
Failure to Update Care Plans After Resident-to-Resident Aggression
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents following incidents of resident-to-resident aggression. Each of these residents had documented episodes of physical aggression toward other residents, which were not subsequently addressed in their care plans through updated goals or interventions. Despite the incidents being discussed in daily and weekly meetings, the care plans were not revised to reflect the new behavioral concerns, and the necessary interventions were not documented for staff reference. For the first resident, who had diagnoses including dementia and intermittent explosive disorder, an incident of aggression occurred, and while immediate actions such as Q15 minute monitoring and provider notification were taken, the care plan was not updated to address the aggressive behavior. The second resident, with Alzheimer's and a history of behavioral symptoms, also exhibited aggression toward another resident. Although this resident's care plan included a general focus on behavioral symptoms, it was not revised to specifically address the new incident of aggression or to add targeted interventions. The third resident, who had multiple psychiatric diagnoses and was hard of hearing, was involved in an altercation where he struck another resident. While staff responded by separating the residents and implementing monitoring, the care plan was not updated to reflect the incident or to include new strategies for managing such behaviors. Interviews with facility staff and leadership confirmed that the incidents were discussed but not thoroughly documented in the care plans, and there was a lack of clarity regarding responsibility for timely care plan revisions following behavioral incidents.
Failure to Inform Residents of Grievance Procedures
Penalty
Summary
The facility failed to provide information to residents and their representatives on their rights related to filing grievances. This deficiency was identified for 12 out of 20 confidential residents, who were not informed about the grievance procedures, did not have access to grievance forms, and were unaware of their right to file grievances anonymously. The residents also did not know who the grievance officer was, how to file a grievance, or their right to receive a written decision regarding their grievances. These issues were highlighted during a Resident Council meeting where residents expressed their lack of knowledge about the grievance process. Observations revealed that the facility did not have instructions regarding grievance procedures posted in prominent locations. Grievance forms were placed in a manila folder on a bulletin board near the nurses' station, but the folder was not accessible to residents in wheelchairs. Additionally, there was an unlabeled wire basket outside the vacant Social Worker's office, which was not covered or secure, for completed grievance forms. The facility's Administrator, who was also the grievance officer, acknowledged the inadequacy of the current system and the lack of resident education on the grievance process. The facility's grievance policy, last updated in 2023, outlines the procedure for filing grievances, including the right to file anonymously and the requirement to provide a written decision within three working days. However, the policy was not effectively communicated to the residents, leading to the deficiency. The Administrator admitted that the grievance process was not discussed in Resident Council meetings and that the current system was not successful in informing residents about their rights and the grievance process.
Deficiencies in Controlled Drug Management and Expired Medication Handling
Penalty
Summary
The facility failed to establish a system for the receipt and disposition of controlled drugs, which led to inaccuracies in drug reconciliation and record-keeping. During an observation, unlogged controlled medications awaiting disposal were found in the storage area. The Director of Nursing (DON) was unaware that these medications needed to be logged upon receipt, prior to their destruction with the pharmacist. The Clinical Resource Nurse confirmed that best practice involves logging discontinued controlled medications upon receipt. The DON admitted to being overwhelmed due to recent changes in facility ownership and her new position, which contributed to the oversight. Additionally, the facility failed to ensure that expired medications were not kept in Medication Cart A. An expired bottle of Vitamin B-12 was found during an observation of the cart. The DON stated that the responsibility for checking medication carts for expired medications lies with the DON, ADON, and nurses, and that audits are conducted regularly. However, the expired medication was missed during recent checks, indicating a lapse in the process. The facility's policies on discontinued medications and disposal of medications require that medications awaiting disposal be logged and stored securely. The policies also mandate that controlled substances be handled, stored, and disposed of according to federal and state regulations. The failure to log and properly manage controlled medications, as well as the presence of expired medications in the cart, could lead to potential negative outcomes such as missing medications and reduced therapeutic effects.
Incomplete OOH-DNR Form for a Resident
Penalty
Summary
The facility failed to ensure that all residents had the right to formulate an advance directive, specifically for one resident whose Out of Hospital Do Not Resuscitate (OOH-DNR) form was missing required information. The resident, an elderly female with multiple diagnoses including peripheral vascular disease, diabetes, schizoaffective disorder, and dementia, had a DNR order noted in her records. However, her OOH-DNR form lacked necessary witness names, signatures, and a notary signature, rendering it incomplete and invalid. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that the facility did not have a social worker, who was responsible for completing the OOH-DNR forms. The DON admitted to not being trained on completing these forms and was unaware of the incomplete status of the resident's OOH-DNR. The ADM confirmed the responsibility of the nursing staff and the DON in ensuring the completeness of these forms but was also unaware of any incomplete forms. The lack of a complete OOH-DNR form could result in the resident's end-of-life wishes not being honored during an emergency.
Failure to Seal Food in Refrigerator
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not sealing foods stored in the refrigerator. During an initial observation of the kitchen, it was noted that slaw and lunch meat were stored in unsealed plastic bags. A follow-up visit revealed that sliced cheese was also stored in an unsealed plastic bag. These observations indicate a lapse in maintaining sanitary conditions for food storage, which could lead to food contamination and foodborne illness. Interviews with the dietary manager (DM) and the administrator (ADM) confirmed that all food in the refrigerator should be sealed, and that all staff had been trained to follow this protocol. The DM and ADM acknowledged the potential negative outcomes of not sealing food, such as food spoilage and cross-contamination. The facility's policy on food storage requires that the dietary manager or a designee check refrigerators and freezers daily to ensure compliance with sanitary conditions, but this was not effectively implemented, leading to the observed deficiencies.
Infection Control Lapses in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by two specific incidents involving residents. In the first incident, a Licensed Vocational Nurse (LVN) did not sanitize his hands between glove changes while performing wound care on a resident with a skin integrity impairment on her left foot. Despite being trained on proper hand hygiene, the LVN admitted to forgetting to use the hand sanitizer available on his cart, which could lead to cross-contamination and infection. In the second incident, a Certified Nursing Assistant (CNA) did not wear a gown while providing incontinent care to a resident on Enhanced Barrier Precautions (EBP) due to a stage 3 pressure ulcer. The CNA acknowledged her mistake, stating she realized the error after starting the care. The facility's policy required the use of gowns and gloves for high-contact care activities, such as changing briefs, to prevent the spread of infections, including drug-resistant organisms. The Director of Nursing (DON) and the Administrator were unaware of these lapses in infection control practices. Both staff members involved had attended recent in-service training on hand hygiene and infection control, yet failed to adhere to the protocols. The facility's policies clearly outlined the necessary procedures for hand hygiene and EBP, emphasizing the importance of using personal protective equipment (PPE) to prevent cross-contamination and the spread of communicable diseases.
Failure to Meet Room Size Requirements
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in multiple resident bedrooms for four semi-private rooms, specifically Rooms #407, 602, 604, and 611. This deficiency was identified through observation, interview, and record review. The facility had previously obtained a waiver for these room size requirements, as documented in the CASPER 3 facility assessment report and the Room Size Waiver for Facilities dated 02/15/24. During the survey, it was noted that these rooms were not currently occupied, as confirmed by the facility's administrator (ADM), who expressed the intention to continue the waiver for these rooms. The ADM stated that the rooms had been under a waiver in the past and were not in use at the time of the survey due to ongoing renovations. The rooms are intended to be used again once renovations are complete and the unit is reopened. Despite the waiver, the facility did not provide a policy related to room size, with the ADM indicating that they followed life safety regulations concerning room size. The lack of compliance with the minimum square footage requirement could potentially place residents at risk of crowding and complicate the provision of care, although this risk was not directly observed as the rooms were unoccupied during the survey.
Resident Abuse Incident by CNA
Penalty
Summary
The facility failed to ensure a safe environment free from abuse for a resident when a social worker witnessed a certified nursing assistant (CNA) slap the resident on the arm. This incident occurred after the resident approached the nurse's station and spat at the CNA, prompting the CNA to react by slapping the resident's arm. The social worker immediately intervened, informed the CNA that such actions were unacceptable, and reported the incident to the administrator and director of nursing. The resident involved in the incident was a male with a history of autistic disorder, symptomatic epilepsy, and bipolar disorder. His care plan indicated a potential for adverse behaviors, including verbal and physical aggression. The resident's cognitive skills for decision-making were noted as modified dependence, with physical and verbal behaviors directed towards others occurring 1-3 days a week. Despite these challenges, the facility failed to protect the resident from abuse by staff. Interviews with the CNA, social worker, and other staff confirmed the occurrence of the incident. The CNA admitted to the action, describing it as a knee-jerk reaction, and acknowledged awareness of the facility's abuse policies. The facility's policy on abuse prevention clearly states that residents have the right to be free from abuse, and staff are trained regularly on these protocols. However, the incident demonstrated a lapse in adherence to these policies, resulting in a deficiency in protecting the resident from abuse.
Infection Control Deficiency
Penalty
Summary
The facility failed to maintain an infection control program, leading to potential risks for infection and cross-contamination for two residents. LVN A did not change her gloves or wash her hands properly during wound care for Resident #1, who had a history of peripheral vascular disease, dementia, type 2 diabetes, and other conditions. Specifically, LVN A did not change gloves or wash hands after cleaning wounds on the resident's chest, left hip, and left ischium, and applied new dressings with contaminated gloves. Similarly, during wound care for Resident #2, who had a history of Alzheimer's, hyperlipidemia, and major depressive disorder, LVN A failed to use proper handwashing techniques. She washed her hands for less than the required 20 seconds and only washed her fingertips. This improper handwashing occurred before and after removing soiled dressings and before applying new dressings to the resident's coccyx wound. Interviews with LVN A, the DON, and the ADM confirmed that the facility's handwashing policy was not followed. LVN A admitted to being trained on proper handwashing but did not adhere to the guidelines during the observed wound care. The DON and ADM both acknowledged the importance of proper handwashing and glove changes to prevent infection but were unaware of the non-compliance until the survey.
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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 Lubbock
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mi Casita Nursing And Rehabilitation Center | 0.2 mi | — | 15 | 0 |
| Lakeside Rehabilitation And Care Center | 0.6 mi | — | 4 | 0 |
| Lubbock Health Care Center | 0.7 mi | — | 6 | 0 |
| Southern Specialty Rehab & Nursing | 0.8 mi | — | 2 | 0 |
| Avir At Lubbock | 1.4 mi | — | 9 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.