Health inspection·February 19, 2025

F 0839 Employ staff that are licensed, certified, or registered in accordance with state laws. Level of Harm - Minimal harm or potential for actual harm **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. Residents Affected - Some 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 the HR Manager, to maintain verifivcation of the licenses and certifications. She stated that prior to the assignment being the responsibility of the HR Manager, there were 2 other staff that had that responsibility. She stated that she assumed that other staff were not doing their job and missed the expiration of the license. She stated that she started early, on [DATE], and checked the registry and found the ADON's license was expired effective [DATE]. She stated that she informed the Administrator and DON, she stated that at that time she let both of them know to take her off the floor. She stated the ADON was removed from the floor and fired [DATE]. During an interview on [DATE] at 2:55 pm. The Administrator stated the ADON submitted her resignation after a personal issue with the facility on [DATE]. She stated the HR Manager made her aware the ADON's nursing license expired effective [DATE] on [DATE]. She stated the ADON was fired at that time the HR Manager informed her of the license issue. She stated Human Resources and the individual staff were responsible for keeping up with the licenses and certifications. She stated after this incident the DON and HR Manager monitored the license and certifications for staff members. She stated they made a referral to the nursing board for the ADON not maintaining her license. She stated they created an Excel Spreadsheet with all of the licenses and training certifications for all CNA and Nursing staff. She stated the DON currently monitors the sheet and keeps her updated weekly on upcoming expirations. She stated the HR Manager also has a spreadsheet and monitors licenses and certification. She provided updates to the Administrator and DON when someone 's license was nearing (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 455617 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455617 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Christian Care Communities and Services Mesquite 1000 Wiggins Pkwy Mesquite, TX 75150 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)