Health inspection·February 11, 2026

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident and the ombudsman of the transfer or discharge and the reason for the move in writing for 1 of 2 residents reviewed for discharge rights. The facility failed to ensure Resident #1 was notified in writing of the details of the transfer. The facility failed to notify the ombudsman of Resident 1's transfer. This failure could affect all residents who were transferred or discharged to another facility at risk of having their discharge rights violated. Findings included:Record review of Resident #1 Face Sheet. dated 02/15/2025 revealed the resident was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that include Parkinsonism, Depression and Schizoaffective Disorder. Record review of Resident #1 MDS assessment dated [DATE] reflected the resident had a BIMS score of 14 indicating no cognitive impairment. Section Q 0400 reflects no Discharge plan in place. Section Q0610 reflects that there was no referral made to the Local Contact Agency. Section Q0620 reflects the reason why no referral was made to the Local Contact Agency was the discharge date was 3 or fewer months. Attempted interview with Resident #1 by telephone on 02/11/1026 at 10:20 a.m. revealed the contact number listed in the Residents records is no longer accepting telephone calls. Attempted email contact with Resident #1 on 02/11/2026 at 10:22 a.m., an email sent to the email address provided for Resident Number #1. No response was received. Attempted interview with Resident #1's daughter by telephone on 02/11/2026 at 10:25 a.m. The phone did not accept message but requested identification before a message could be left. There was no message left. Interview with the Ombudsman on 02/11/2026 at 11:30 a.m revealed she was concerned that the facility did not notify the resident of why she was moved to the sister facility. She stated that the resident told her she did not know why they moved her. She stated the facility staff had not notified her of any discharge or transfers. She stated she visited another facility and Resident#1 informed her of transfer to that facility. Interview with administrator on 02/11/2026 at 12:30 p.m. revealed the Social Worker was on leave and was the one who arranged the transfer. She stated that they transferred Resident #1 to a sister facility. She stated that they were having ongoing problems with Resident #1 getting along with a roommate and she also desired a private room. She did not qualify for a private room, but there was room at another facility. She stated that the resident agreed to the transfer and was transferred to the facility. She stated that the Resident was in agreement with the transfer. She stated that she was not able to locate any written correspondence notification. She stated that they had not been in the practice of notifying the ombudsman of transfers and discharges unless there were special circumstances. She stated that she will review the policy to confirm the situations in which they have to notify the ombudsman of moves and discharges. Record review of facility policy Transfer and Discharge (including AMA) Dated 10/10/2017 reviewed 09/01/2023 Policy Explanation and Compliance Guidelines:The facility will evaluate and determine the level of care needed for the resident prior to admission toensure the facility's ability Page 1 of 2 675033 675033 02/11/2026 Mesquite Tree Nursing Center 434 Paza Dr Mesquite, TX 75149

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to meet the resident's needs The facility permits each resident to remain in the facility and not transfer or discharge the resident from the facility except in limited situations when the health and safety of the individual or other residents are endangered.The facility may initiate transfers or discharges in the following limited circumstances:The transfer or discharge is necessary for the resident's welfare and the resident's needs cannotbe met in the facility. The resident's health has improved sufficiently so that the resident no longer needs the care and/or services of the facility. The safety of the individuals in the facility is endangered due to the clinical or behavioral status of the resident.The health of the individuals in the facility would otherwise be endangered. The resident has failed, after reasonable and appropriate notice, to pay or have paid under Medicare or Medicaid for his or her stay at the facility.The facility ceases to operate. 1. Non-Emergency Transfers or Discharges - initiated by the facility, return not anticipated.a. Document the reasons for the transfer or discharge in the resident's medical record, and in the case of necessity for the resident's welfare and the resident's needs cannot be met in the facility, document the specific resident needs that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the needs. Document any danger to the health or safety of the resident or other individuals that failure to transfer or discharge would pose.b. At least 30 days before the resident is transferred or discharged , the Social Services Director will notify the resident and the resident's representative in writing in a language and manner they understand. (This time frame does not apply if the resident has not resided in the facility for 30 days.)c. Contents of the notice must include:i. The reason for transfer or discharge;ii. The effective date of transfer or discharge;iii. The location to which the resident is transferred or discharged ;iv. A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; and v. The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman. 675033 Page 2 of 2