Health inspection·December 15, 2022

F 0584 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #106's face sheet, undated, revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with a primary diagnosis of Alzheimer's disease. Record review of Resident #203's face sheet, undated, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of dementia. Residents Affected - Some Record review of Resident #204's face sheet, undated, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with a primary diagnosis of diabetes (high blood sugar). During an observation and interview on 12/13/2022 at 10:00am Resident #36 was lying in bed completely covered with two blankets to the bottom of his chin with his arms in the blanket. Interview with Resident #36 he stated he was freezing under his two blankets, Resident #36 stated he was always cold in his room. Resident #36 stated he has told staff he is cold many times, but the temperature does not change. During an interview and observation on 12/13/2022 at 10:10 AM Resident #22 was rubbing her arms when surveyor entered the room. She stated she is cold and needed her jacket. She stated she got dressed and out of bed to move around because she was freezing. She stated her room is always freezing, she has never heard the heater come on, nor felt the heater come on and her bed is right under the vent for the heater. She stated she has complained to staff about the temperature of her room several times, but nothing improves. During an interview on 12/13/22 at 10:30 AM with Resident #30 complained it was cold in his room. Resident sitting up in wheelchair with blanket over his legs. He stated they have no way to control the temperature in their room. He stated he was told they could not turn up the temperature because the dining rooms gets too hot. He stated he spoke with maintenance and was told the thermostat controls are in the DON's office. During an interview and observation on 12/13/22 at 10:35 AM with the DON she stated the thermostat controls are behind a panel in her office. Thermostats for the facility was observed to be located behind panel in DON office. Thermostat labeled Hall 100 revealed a temperature of 72° F. DON stated she adjust them by one degree when residents complains of being hot or cold. She stated, I know who you are talking about and they have been offered a blanket and he refuses to take one. During an interview on 12/13/2022 at 11:30 AM Resident #204 stated her room is always cold, she never feels warm in her room, she has never heard the heater come on, she has never felt warm air from the vent in her room. She stated she always wears several layers of clothes and covers herself in several blankets. She stated she has reported the cold temperature of her room to several staff, the temperature has not improved. During an observation and interview on 12/13/22 at 12:13 PM Resident #30 sitting in his wheelchair under a blanket, covering his head. He stated the temperature was too cold. He stated that he had told the maintenance staff member about it that morning and was told they would adjust the temperature. During an interview on 12/13/22 at 2:34 PM, Resident #1 stated the facility is cold a lot of the time here lately. He stated that it is freezing cold and gets worse at night. He stated he has told the maintenance staff member before. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 2 of 15 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 676163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesquite Post Acute Care 4510 27th St Lubbock, TX 79410 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)

F 0584 During an observation on 12/14/22 09:00 AM using surveyor's thermometer revealed the following: room [ROOM NUMBER]: 67.6° F Level of Harm - Minimal harm or potential for actual harm During an observation on 12/14/22 at 09:30 AM, using surveyor's thermometer revealed the following: Residents Affected - Some End of Hall 200: 67.8° F room [ROOM NUMBER]: 67.6° F Front of Hall 200: 69.5° F room [ROOM NUMBER]: 70.4° F room [ROOM NUMBER]: 70.3° F room [ROOM NUMBER]: 70.6° F During an interview and observation on 12/14/22 at 09:35 AM with Resident #48, she stated Yes, I am cold. Resident #48 lying in bed with blanket coving her. Resident #48 room temperature using surveyor's thermometer was 70.4° F. During an interview on 12/14/2022 at 9:35 AM Resident #6 stated her room is consistently cold, she is never warm in her room, she has three blankets on her bed, and wears several layers of clothes. She stated she has reported her temperature concerns to staff; however, the temperature of her room has not changed. During an observation on 12/14/2022 at 1:30 PM surveyor observed Resident #36 asked a staff member to turn the heater up for his room as he was cold. During an observation on 12/14/22 at 02:44 PM, using surveyor's thermometer revealed the following: room [ROOM NUMBER]: 70.0° F End of Hall 200: 69.4° F room [ROOM NUMBER]: 69.6° F Front of Hall 200: 70.5° F room [ROOM NUMBER]: 70.0° F End of Hall 100: 70.6° F During an observation on 12/14/22 at 03:00 PM observed thermostats in DON office revealed the following: Thermostat labeled Dining hall set to 69° F with a current temperature 71° F. Thermostat labeled Hall 100 set to 71° F with a current temperature 70° F. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 3 of 15 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 676163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesquite Post Acute Care 4510 27th St Lubbock, TX 79410 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)

F 0584 Thermostat labeled Hall 200 set to 70° F with a current temperature 70° F. Level of Harm - Minimal harm or potential for actual harm Thermostat labeled Hall 300 set to 70° F with a current temperature 72° F. Thermostat labeled Therapy/Med Room set to 69° F with a current temperature 71° F. Residents Affected - Some Thermostat labeled No label set to 69° F with a current temperature 71° F. Thermostat labeled ADON set to 68° F with a current temperature 70° F. During an interview on 12/14/22 at 03:15 PM with maintenance supervisor, he stated each hall has 3 temperature sensors that go to the thermostats. He stated he checks temperatures inside the facility weekly on Fridays. He stated he has never seen a setup where all the thermostats are located in one room. During an observation on 12/15/2022 at 11:01am Resident #203 seated on the side of his bed blanket covered his head, wrapped around his shoulders, with his hands clinging to the inside of the blanket. During an observation on 12/15/22 at 11:03 AM, using surveyor's thermometer revealed the following: room [ROOM NUMBER]: 67.7° F room [ROOM NUMBER]: 68.5° F Front of Hall 200: 69.9° F room [ROOM NUMBER]: 69.7° F During an observation on 12/15/22 at 12:45 PM, with Maintenance Supervisor, using his temperature gun he registered the following temperatures: End of Hall 100: 67.4° F room [ROOM NUMBER]: 67.8° F End of Hall 200: 68.3° F End of Hall 300: 69.0° F During an observation and interview on 12/15/22 at 01:25 PM, Resident #36 requested an additional blanket because he was cold. Room temperature using surveyor's thermometer was 68.6° F. Resident #36 stated I'm so cold, I have the shakes. During an interview on 12/15/22 at 02:34 PM with MA A, he stated he has noticed the building cold at times. He stated when residents complain they are cold he will get them an additional blanket. He stated he is not able to adjust the temperature in the facility. He stated if the temperature needs to be adjusted, they call the DON or maintenance supervisor. He stated the potential negative outcome of residents being cold is they could get ill. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 4 of 15 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 676163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesquite Post Acute Care 4510 27th St Lubbock, TX 79410 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)

F 0584 Level of Harm - Minimal harm or potential for actual harm During an interview on 12/15/22 at 02:38 PM with RN A, she stated if residents are complaining they are cold she will get them an extra blanket. She stated she also encourages the residents to keep room doors open so the air can circulate and that helps warm the rooms. She stated she is not able to adjust the facility temperature. She stated if the temperature needs to be adjusted, she calls or text the DON or maintenance supervisor. She stated the potential negative outcome for a resident to be cold is they could get sick. Residents Affected - Some During an interview on 12/15/22 at 02:42 PM CNA A, she stated in the mornings she has noticed it was cold in the facility. She stated residents have complained to her about it being cold but not that often. She stated she lets the nurse know when a resident complains about the temperature and lets the maintenance man know as well. She stated she would make sure they are wearing warm clothes and get them to a warmer space like the dining room or a more central place in the building. She stated she thinks the maintenance man is the only person she is aware of that has access to control the temperature in the facility. She stated the potential negative outcome for a resident who is often cold in the facility would be they would be uncomfortable and possibly not able to sleep. During an interview and observation in room [ROOM NUMBER] on 12/15/22 at 02:45 PM with the administrator, she stated she felt room [ROOM NUMBER] was cold. She stated she felt room [ROOM NUMBER] was approximately 68° F. The room temperature using the surveyor's thermometer was 66.7° F. She stated residents have reported within the past three weeks they are cold. She stated she called a repairman, and the unit was serviced. She stated the DON controls the thermostat in her office. She stated she requests maintenance take temperatures throughout the building if there are complaints about temperatures. She stated she was not aware of the resident in this room complaint of being cold and shivering. She stated the potential negative outcome for residents who are consistently cold are an increase in flu, hypothermia, and she wanted residents to be warm and comfortable in their home. Record review of a policy provided by facility titled Facility Temperatures with a revised date September 2021. Policy Statement: To maintain a safe comfortable temperature environment for residents. Definitions: The legislature adopted Minimum Design Standards for Health Care Facilities by reference on December 30th, 2002 [Public Act 683 of 2002, MCL 333.20145}, and those standards specify minimum and maximum temperature levels for nursing homes, including a range of 71 to 81 degrees for resident rooms, and for isolation rooms. Policy Interpretation and Implementation: Policy: Residents' rooms that allow a resident to control the temperature, then the resident could maintain his or her room at any level desired, unless the temperature adversely affects the health, safety, or comfort of any resident. The minimum and maximum temperature levels for facility is a range between 71 and 81 degrees. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 5 of 15 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 676163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesquite Post Acute Care 4510 27th St Lubbock, TX 79410 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)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that all allegations involving abuse, neglect, exploitation or mistreatment of resident property are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including the State Survey Agency in accordance with State law through established procedures for all residents in the facility The facility failed to report that Resident 106 was allegedly touched under her pajama pants by Resident 27, during the same incident an attempt was made by the same resident to touch Resident 106 under her brief while Resident 106 was sleeping. This failure could place residents at risk of not receiving the care required to meet their physical, mental, and psychosocial needs to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings include: Record review of Resident 106's undated admission record revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnosis of alzheimer's disease, abnormalities of gait and mobility,breast cancer, arthritis, hypothyroidism,gastro-esophageal reflux, major depressive disorder. Record review of Resident 106's last Comprehensive MDS Assessment, dated 12/2/22, revealed a BIMS score of 15, which indicated the Resident is cognitively intact. Record review of Resident 27's undated admission record revealed an [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses of type 2 diabetes (high blood sugar), psychotic disorder with delusions due to known physiological, dementia with behavioral disturbance, depressive disorder, cognitive communication deficit, anxiety, sleep apnea, osteoporosis. urinary tract infection, nicotine dependence, insomnia, hypertension. Record review of Resident 27's last MDS was an annual completed 10/10/2022 with a BIMS of 3 indicated she was severely cognitively impaired. Interview resident 106 stated on 11/22/2022 in the middle of the night, resident was unsure of time, Resident 27 woke her up as she (Resident 27) was placing her hand under Resident 106's pajama pants and then attempting to place her hand inside Resident 106's brief around the inner thigh area close to her vagina. Resident 106 stated she fought Resident 27 off with her hands and by yelling get off of me. Resident 106 stated staff eventually came into the room and escorted Resident 27 out of her room. Resident 106 stated she reported to staff the incident with Resident 27 as soon as they came into the room. Resident 106 stated she felt staff made excuses for Resident 27's behavior. Resident 106 stated she did not remember the name of the staff member she reported to at the time of the incident. Resident 106 stated she reported the incident to Admin the next day. During an interview on 12/14/2022 2:00pm during with Resident, roommate to Resident 106, stated she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 6 of 15 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 676163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesquite Post Acute Care 4510 27th St Lubbock, TX 79410 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)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was woken up in the middle of the night on 11/22/22 by Resident 106 yelling for help and telling Resident 27 to get away from her. Resident 10 stated she was unsure what staff came into the room that night; she too stated staff were making excuses for Resident 27's behavior. During an interview on 12/15/22 02:15pm with DON: She said that the incident was not reported because the Resident 106's story kept changing and Resident 106 could not tell them if it was Resident 27s or not. She said the resident thought it could have been an aid or Resident 27. She said the abuse coordinator is the administrator and she is responsible for reporting although she said she (DON) does help out with that as well. DON said it was reported to them on the 28th of November so it should have been reported that day preferably. She said the potential negative outcome could be that it could happen again. She said she has had ANE training and that it included the topic of sexual abuse, she said its part of the competencies they do as well as in-services yearly. She said training is in person, they print off the policies and procedures of ANE and then go over them during an in service. She said whoever does not come to that in-service she goes to in service them individually when they are working. She said they have a policy called abuse investigation and reporting in which the roles of each position are outlined. She said she tells the staff that they need to notify the Admin and DON immediately of incidents concerning ANE so that reports to the state can be submitted. During an Interview on 12/15/22 at 02:19pm Interview with LVN A: She said she was aware of the situation but wasn't aware of the inappropriate touching. LVN A was told that s was just going in and removing blankets and sheets. She said she has had ANE training which covered sexual abuse and who to report to. She said reporting is made to the administrator as well as the social worker. She said she thinks the incident was reported to the DON and said that the DON was not working the night that it happened and was working from home the next day. She said the person that witnesses the incident should report it to the administrator or the charge nurse whose shift it is on would be responsible for reporting. She said ANE training that she had was a meeting where they were asked several questions regarding the types of abuse and who to report to and to name the types of abuse. She said if they did not know the answer, but received the information. She said if she had been the nurse working that shift when the incident occurred, she would have separated the residents and kept her eyes on Resident 27 and looked into a temporary bed change to separate them further then report the incident to the admin and oncoming shift to address the situation and consider a more permanent solution. During an Interview on 12/15/22 at 2:39pm with CNA A (Agency but has worked here past two months) She said she was not aware of the incident but only works days. She said she has had ANE training and she is aware that sexual abuse is a form of abuse. She said training consisted of an in-service with the abuse coordinator where they were asked to list the types of abuse. She said if she witnessed it she would stay with the resident and have someone go get the nurse and make sure the other resident was removed. She said she would report to the abuse coordinator. During an Interview on 12/15/22 at 1:45pm with ADON who has been employed by the facility for 4 years stated she was made aware of the incident between Resident 106 and Resident 27 by the DON. ADON stated DON and the Admin are the abuse coordinators, ADON stated the DON made the decision not to report the incident because the DON stated Resident 106's story kept changing. ADON stated she informed the DON she felt the incident should be reported to the state; DON continued to disagree with the ADON. ADON stated she was told by the DON to call Resident 27's physician and request a medication change or increase; ADON completed this task, ADON stated the physician ordered Paxil for Resident 27. ADON stated she was told not to document the incident in electronic records, she was told to only document the additional medication for Resident 27. ADON stated the incident should have been reported immediately; ADON stated she was trained on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 7 of 15 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 676163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesquite Post Acute Care 4510 27th St Lubbock, TX 79410 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)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few abuse and neglect to report abuse immediately to the abuse coordinator. ADON stated the potential negative outcome for abuse not being reported to the State is other residents are put at risk for abuse and neglect. Record review on 12/15/22 at 2:45pm of facility's documentation regarding the incident with Resident 106 and Resident 27 revealed there was no documentation of the incident. The addition of Paxil for Resident 27 was the only documentation for 11/22/22 in Resident 27's electronic record. There was no documentation of the incident in Resident 106's electronic record. Record Review of previous investigations for the facility from 11/15/2022-12/12/2022 revealed the incident between Resident 106 and Resident 27 was not reported to the State. Policy: Record review of the facility's policy labeled, Resident Rights and Dignity: Abuse and Neglect - Clinical Protocol, Revised July 2017, documented the following, . 5. The Administrator, or his/her designee will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 8 of 15 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 676163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesquite Post Acute Care 4510 27th St Lubbock, TX 79410 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)

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I screening accurately reflected the resident's status for 3 of 6 residents (Residents #30, #32, #38) reviewed for PASRR services. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Residents #30, #32, and #38, which resulted in the residents not receiving a PASRR Level II evaluation. This failure could place residents who have a mental illness at risk of not receiving individually specialized services to meet their needs. Findings included: Resident #30: Record review of Resident #30's face sheet dated 3/24/2022 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including bipolar disorder (onset date 3/24/3022), pseudobulbar affect (Condition that is characterized by episodes of sudden uncontrolled laughing or crying, onset date of 3/24/2022), and manic episode (onset date of 3/24/2022). Record review conducted on 12/19/2022 at 9:39 AM of Resident #30's history and physical dated 8/24/2022 contained diagnoses which read pseudobulbar affect, bipolar disorder, current episode depressed, mild or moderate severity, unspecified, manic episode, unspecified. Record review conducted on 12/19/2022 at 9:43 AM of Resident #30's MDS assessment dated [DATE] revealed a BIMS score of 13 out of 15 indicating he was cognitively intact. Record review conducted on 12/19/2022 at 9:54 AM of Resident #30's undated care plan contained a focus area which read I require assist with ADLs and am at risk for deterioration in ADLs: (bed mobility, bathing, transfer, walking in room, walking in corridor, locomotion on unit, locomotion off unit, dressing, eating, toilet use, personal hygiene) R/T cognitive impairment with interventions that included Explain the expected prognosis and the expected therapy outcomes. Record review conducted on 12/19/2022 at 9:45 AM of Resident #30's PASRR Level 1 screen dated 3/15/2022 revealed the following in part, .C0100. Mental Illness: Is there evidence or an indicator this is an individual that has a mental illness . The answer was No. An observation made on 12/13/22 at 12:13 PM showed Resident #30 to be sitting in his wheelchair under a blanket, covering his head with the blanket. When spoken to, he did not remove the blanket until a few minutes later and appeared to have a depressive affect. Resident #32: Record review of Resident #32's face sheet dated 4/23/2021 revealed a [AGE] year-old male admitted on [DATE] with diagnoses listed including schizoaffective disorder, bipolar type with onset date of 7/11/2022. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 9 of 15 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 676163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesquite Post Acute Care 4510 27th St Lubbock, TX 79410 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)

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review conducted on 12/19/2022 at 10:09 AM of Resident #32's history and physical dated 10/21/2022 contained diagnoses which read unspecified psychosis not due to a substance or known physiological condition. Record review conducted on 12/19/2022 at 10:12 AM of Resident #32's MDS assessment dated [DATE] revealed a BIMS score of 6 out of 15 suggesting severe cognitive impairment. Record review conducted on 12/19/2022 at 9:54 AM of Resident #30's undated care plan contained a focus area which read I have cognitive impairment with interventions in place which included Involve me in care as to maintain or increase level of independence. Additionally, a focus area was included which read cognitive skills for decision making moderately impaired with interventions that included encourage resident to participate in activities of choice and explain regular routine to resident and give medications as ordered and monitor for side/adverse effects. Record review conducted on 12/19/2022 at 10:19 AM of Resident #32's PASRR Level 1 screen dated 4/23/2021 revealed the following in part, .C0100. Mental Illness: Is there evidence or an indicator this is an individual that has a mental illness . The answer was No. During observation and interview conducted on 12/13/22 at 11:02 AM Resident #32 was observed sitting in the dining room on a couch. Resident #32 stated things are pretty much alright here. He was not very talkative and had a flat affect. Resident #38: Record review of Resident #38's face sheet dated 6/24/2020 revealed a [AGE] year-old male admitted on [DATE] with diagnoses listed including major depressive disorder (onset date of 6/24/2020), mood disorder due to a known physiological condition with major depressive-like episode (onset date 7/22/2020), cognitive communication deficit (onset date of 6/24/2020), psychotic disorder with delusions due to known physiological condition (onset date of 7/16/2020), anxiety disorder due to know physiological condition (onset date of 6/24/2020), and vascular dementia with behavioral disturbance (listed as a secondary diagnosis with onset date of 7/22/2020). Record review conducted on 12/19/2022 at 2:06 PM of Resident #38's MDS assessment dated [DATE] revealed a BIMS score of 5 out of 15 suggesting severe cognitive impairment. Record review conducted on 12/19/2022 at 2:07 PM of Resident #38's undated care plan contained focus areas which read Resident #38 has a cognitive impairment. Additionally, a focus area related to assistance with activities of daily living was listed as being related to a cognitive impairment. Lastly, the care plan contained a focus area which read Resident #38's cognitive skills for decision making- moderately impaired. Record review conducted on 12/19/2022 at 10:19 AM of Resident #38's PASRR Level 1 screen which was performed on 6/24/2020 revealed the following in part, .C0100. Mental Illness: Is there evidence or an indicator this is an individual that has a mental illness . The answer was No. During an interview conducted on 12/15/22 at 10:24 AM, the DON said the PASRR assessments were currently being updated by the MDS coordinator, after surveyor intervention. She said they were being redone to accurately reflect diagnoses for the residents in question, and that someone was coming that evening to conduct a level two evaluation of these residents. She said they would have paperwork (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 10 of 15 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 676163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesquite Post Acute Care 4510 27th St Lubbock, TX 79410 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)

F 0644 together by that afternoon. Level of Harm - Minimal harm or potential for actual harm During an interview conducted on 12/15/22 at 11:00 AM, the MDS coordinator said the PASRR level one screenings had been updated and submitted in Simple LTC and that she had spoken with the PASRR coordinator from the local mental health authority. She said the PASRR coordinator was planning to come conduct a level 2 evaluation of the residents (Residents #30, #32, #38) this afternoon. She said the risk of not having level one PASRR screening accurately reflecting medical diagnoses of mental illness was that the residents would not receive recommended services that they had a right to. When asked what was meant by the term updated, she said she meant that the PL1s were corrected to accurately reflect medical diagnoses for the residents since they currently indicated no in areas C0100, C0200, and C0300. Residents Affected - Some During an interview conducted on 12/15/22 at 1:45 PM, the MDS coordinator it was the responsibility of the MDS coordinator to conduct a level one PASRR screening of residents. She said she had been the MDS coordinator at for this facility for about a month and that she was full time at another facility and has picked up at this facility because the MDS coordinator they had was no longer there. She said anyone with access to the system can enter a PL1. She said normally the PL1 was conducted by the previous facility if the resident is coming from another facility. She said if the resident was coming from the community, then the MDS coordinator should have asked the assessment questions to the family or the resident, if they can answer reliably. She said if the resident comes from another facility, then the person entering the PL1 should verify accuracy by looking at medical diagnoses. She said she is usually the person who enters the PL1. She said usually she would make updates to the PL1 if needed. She said other staff members can assist, but usually she would be the one that updates and verifies diagnoses. When asked if schizoaffective disorder, bipolar disorder (BPD), and major depressive disorder (MDD) were diagnoses that would be considered a mental illness, she said yes, they all are. She said the PL1s for these residents (#30, #32, and #38) were done by people she had never met, and she did not know if they were an outside facility or could have been done at a hospital. During an interview conducted on 12/15/22 at 2:10 PM, the DON said the PL1 is the responsibility of the MDS coordinator. She said when a resident comes from another facility, they are supposed to send the PASRR already completed. She said the MDS coordinator should go over the PL1 to verify for accuracy. She said the MDS coordinator makes updates for any changes in medical diagnoses or incorrect PL1 screenings. She said all three diagnoses, schizoaffective, BPD, and MDD, are mental illnesses and should have been marked as yes in section C0100 on the PL1 screening form. She said she did not know why the PL1s were marked as no for the three residents because they were admitted before she was working at the facility. She said she had been working at [NAME] Terrace since August of 2022. She said the potential risk for a resident whose PL1 screening was not accurate would be the resident may not get extra benefits such as therapy and certain needed equipment. During an interview conducted on 12/15/22 at 3:10 PM, the PASRR Coordinator said she had just arrived at the facility to evaluate the three residents that she was informed about (Resident #30, #32, #38). She said once a positive PL1 is entered into Simple LTC, then and only then can she come to the facility to perform a level 2 evaluation. Record review of Form 1012, Texas Health and Human Services Mental Illness/Dementia Resident Review found at https://www.hhs.texas.gov/regulations/forms/1000-1999/form-1012-mental-illnessdementia-resident-review (accessed on 12/19/2022) read in part, .Examples of MI (mental illness) are: a schizophrenic, mood disorder (bipolar, major depression, or other mood disorder), paranoid disorder; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 11 of 15 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 676163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesquite Post Acute Care 4510 27th St Lubbock, TX 79410 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)

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some somatoform disorder; schizoaffective disorder; panic or other disorder that may lead to a chronic disability diagnosable under the current Diagnostic and Statistical Manual of Mental Disorders . Record review conducted on 12/21/2022 at 11:26 AM of the State Operations Manual, Appendix PP, under

F646, section 483.20 (k)(4), definitions, reads Preadmission Screening and Resident Review (PASARR) is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care. PASARR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated for a serious mental disorder and/or intellectual disability; 2) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care setting); and 3) receive the services they need in those settings. Record review conducted on 12/21/2022 at 11:39 AM of facility policy titled Antipsychotic Medication Use, with a revision date of December 2016, read in part Complete PASRR screening (preadmission screening for mentally ill and intellectually disabled individuals), if appropriate. Record review conducted on 12/21/2022 at 11:40 AM of a facility policy titled Behavioral Assessment, Intervention and Monitoring, with a revision date of December 2016, read in part As part of the initial assessment, the nursing staff and Attending Physician will identify individuals with a history of impaired cognition, altered behavior, or mental illness (e.g., bipolar disorder or schizophrenia). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 12 of 15 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 676163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesquite Post Acute Care 4510 27th St Lubbock, TX 79410 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. 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 residents who consumed food orally from 1 of 1 facility kitchen in that: 1) Foods were not protected from contamination during storage (dry food storage). 2) Food equipment was not maintained clean and in good repair (refrigerator). These failures could place residents at risk of foodborne illness. The findings include: The following kitchen observations were made beginning on 12/13/22 at 9:30 AM and concluding at 10:10 AM: The outside doors and handles of refrigerators in the main kitchen were soiled with an accumulation of dried food. The inside of fridge had crumbs and liquid substance on the bottom of fridge. There was white sticky accumulation on inside walls and doors. The seals on the refrigerator doors were worn and falling off. In the pantry, there were a large accumulation of white powder under the dry food storage self. During an interview on 12/15/22 at 10:50 AM Dietary Aide A stated, refrigerators are cleaned weekly and as needed, but since they have been short staffed it's been hard. She stated she was not sure if the seals had been reported to maintenance. She stated the white powder stuff under the dry for storage self was something coming from the crack tile above the dry food storage self. During an interview on 12/15/22 at 11:25 AM Dietary Manager stated she does have a cleaning schedule, but she has been adjusting it and has not got it printed and hung back up. She stated, the refrigerators are to be cleaned two times a week, but she has been short staffed, so it has not been done. She stated she had reported to the maintenance man the seals were bad on the refrigerators. She stated if the seals are not properly sealing the temperature in the refrigerator will go up and not keep food at proper temperature. She stated the white powder under the dry food self is coming from the cracker tiles above the self. Stated they clean under the self and wash out the dry food bins daily. She stated the crack had been reported to maintenance and it was sealed on the outside, but it continues to drop white powder. During an interview on 12/15/22 at 02:45 PM Maintenance Supervisor stated he was not aware the seals on the refrigerator needed to be replaced. He stated he did seal the cracks in the dry goods panty. He stated if the seals are not working properly on the refrigerator it could cause the refrigerator to lose coolness. Record review of a policy provided by facility titled Sanitization with a revised dated October 2008. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 13 of 15 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 676163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesquite Post Acute Care 4510 27th St Lubbock, TX 79410 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)

F 0812 Policy Statement: The food service area shall be maintained in a clean and sanitary manner. Level of Harm - Minimal harm or potential for actual harm Policy Interpretation and Implementation: 1. Residents Affected - Many All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. 2. All utensils, counters, shells and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosion, open seams, cracks and chipped areas that may affect the use or proper cleaning. Seals, hinges and fasteners will be kept in good repair. 3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitize using hot water and or chemical sanitizing solutions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 14 of 15 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 676163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesquite Post Acute Care 4510 27th St Lubbock, TX 79410 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)

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on interview and record review, the facility failed to provide at least 80 square feet per resident in multiple resident bedrooms for 4 (Rooms #407, 602, 604 and 611) of 48 semi-private rooms reviewed for physical environment. The facility failed to ensure resident Rooms #s 407, 602, 604 and 611 met the required minimum of 80 square feet per resident. This failure could place residents at risk of crowding and cause difficulty in providing resident care. Findings include: Record review of CASPER 3 during preparation for survey revealed a waiver for room size requirements had been done yearly by the facility. Record review of Room Size Wavier for Facilities dated 10/12/21, during preparation for survey, revealed a wavier for rooms #s 407, 602, 604, and 611. Record review of Texas Health and Human Services Form 3740 (Bed Classifications (Numbers and Location) dated 12/13/22 documented that Rooms #'s 407, 602, 604 and 611 were listed as a Title 18/19 bed classification semi-private rooms for two residents. During an interview on 12/13/22 at 09:15 AM with the Administrator regarding the square footage for Room #'s 407, 602, 604 and 611. When asked if she wanted to apply for the room size waiver she stated, Yes, I want to apply for the waiver. The ADMIN stated Room #'s 407, 602, 604, and 611 had a waiver in the past. She stated, the rooms are not being used at this time but will if they open that unit back up. During an observation on 12/13/22 from 10:00 AM to 10:30 AM, observed the following rooms: Rooms 407,602, 604 and 611 not occupied. During an interview on 12/13/22 at 10:30 AM with the Administrator, regarding the risk of residents not having the appropriate space, she stated it had not been a problem in the past . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 15 of 15