Health inspection·December 22, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few treatments. Family Member A said that providing care was a part of LVN A's job but that she should not speak to Resident #1 in the tone that she had. During an interview conducted on 12/21/23 at 11:00 AM, the ADM stated she was the abuse preventionist. She said that suspicion of ANE should be reported to her immediately. She stated she expected staff or herself, as the abuse preventionist, to remove the resident from the situation. She said even if it were 2:00 in the morning, she would still investigate the allegation. She stated she had 2 hours to report any allegations of ANE to state if she concluded that there was abuse. She said she had not had any reports of ANE. During an interview conducted on 12/22/23 at 3:04 PM, the ADM stated that she did not report the allegations of abuse because she felt that Family Member B was not saying that she thought that Resident #1 was abused. She stated Family Member B said LVNA A was not speaking directly to Resident #1. She stated that Family Member B said that LVN A redirected her mother. She stated she did not know why Family Member B thought the verbal redirection from LVN A was mean. She stated that she had not spoken with LVN A since the report from Family Member B. She said she had not talked to LVN A because she was asleep. She said LVN A was on duty when the information was reported to her. She stated she did not know why she did not call her (LVN A) when Family Member B reported LVN A was rude to Resident #1. She stated it may have been because it was late. She said that she talked with the staff, and they had not seen anything. She stated she had no witness statements or evidence indicating that she spoke with staff. She also said that during previous safety surveys, Resident #1 had never expressed any concerns about her safety. A record review of text messages provided by Family Member A revealed that on 12/20/23 at 8:13 PM, Family Member B informed the ADM that Sunday (12/17/23), that nurse, which was later identified as LVN A by the ADM, was rude to Resident #1. She expressed that if Resident #1 was in her right mind, Resident #1 would not act as she does. Family Member B said Resident #1 had experience as a certified nurse aide and would have never talked to her patients the way LVN A spoke to Resident #1. Family Member A said Resident #1's heart would have been broken if she was LVN A's CNA because of how she treated Resident #1. Family Member B said she had to hold back, not say anything to LVN A, and focus on taking care of Resident #1. Family Member B said that when she was walking Resident #1 to her room, LVN A stopped her, and LVN A said, [Resident #1] better not have another night like the last few nights. Family Member B said LVN A was upset at Resident #1 and kept saying how mad she was because she had to write a long note about Resident #1 sending a male resident to the female area of the facility. She said LVN A's tone was an issue and that she had to tune her out because she kept repeating herself. The ADM responded in the text message and stated she would talk with LVN A. Record review of Salesforce TULIP show no report submitted to include LVN A and Resident #1 as 12/21/23. Review of facility's policy, Abuse Investigation and Reporting, Revised July 2017, revealed: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Reporting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 2 of 6 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 12/22/2023 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 All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation on property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: The state licensing/certification agency responsible for surveying/licensing the facility; Residents Affected - Few An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but no later than: ~Two (2) hours if the alleged violation involves abuse or has resulted in serious bodily injury; ~Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 3 of 6 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 12/22/2023 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to have evidence that all alleged violations were thoroughly investigated for 1 of 5 allegations reviewed for resident abuse (Resident #1). Residents Affected - Few The facility failed to ensure an allegation of abuse between Resident #1 and LVN A was thoroughly investigated. This failure placed residents at risk of unidentified abuse. Findings included: Record review of Resident #1's face sheet, dated 12/21/23, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnosis to include anxiety and dementia (cognitive loss related too remembering and reasoning) Record review of Resident #1's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 06, which indicated the resident's cognition was severely impaired. During an interview on 12/21/23 at 9:00 AM, Resident #1 stated all staff were nice to her. She said she had no concerns with any staff that worked with her. During an interview on 12/21/23 at 10:23 AM, Family Member B stated that LVN A had a bad tone with Resident #1. She stated that LVN A told Resident #1 directly, We are not going to have another night like last night. She said she reported this to the ADM on 12/20/23. Family Member B stated that she felt like it was verbal abuse to Resident #1 because of the tone that LVN A used. She stated she would never want anyone to talk to her or her family in the tone that LVN A spoke to Resident #1. She said that it hurt her heart for LVN A to speak to Resident #1 in the tone that she used. She stated LVN A had told her that Resident #1 slapped her leg and laughed at an incident concerning a male resident going on a female hall. She said Resident #1 was not in her right mind. She stated that LVN A's tone could be described as a scolding. She stated it was almost like LVN A was saying, You better not do that again, when she said they better not have another night like the previous one. She stated she had heard other nurses speak to Resident #1 and redirect her, but not in the tone that LVN A used. She said that LVN A stated she loved Resident #1, which was why she did all of Resident #1's treatments. Family Member A said that providing care was a part of LVN A's job but that she should not speak to Resident #1 in the tone that she had. During an interview conducted on 12/21/23 at 11:00 AM, the ADM stated she was the abuse preventionist. She said that suspicion of ANE should be reported to her immediately. She stated she expected staff or herself, as the abuse preventionist, to remove the resident from the situation. She said even if it were 2:00 in the morning, she would still investigate the allegation. She stated she had 2 hours to report any allegations of ANE to state if she concluded that there was abuse. She said she had not had any reports of ANE. During an interview conducted on 12/21/23 at 9:35 PM, LVN A stated that on 12/17/23, she notified the resident's family that Resident #1 had been waking up her roommate. She said she told the family (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 4 of 6 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 12/22/2023 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few about Resident #1 having a black male resident go down the hall where the other female residents were and laughing at the incident. She said they talked about Resident #1 interfering with Resident's care. She stated she also told Family Member B that Resident #1 refused showers. She said Family Member B never expressed that she was upset. She explained that the ADM did not inquire if there had been any issue with Resident #1 or Family Member B. She stated the ADM only warned her that she needed to be careful because Family Member B complained that she (LVN A) was rude to them. She stated that she worked the remainder of her shift and was never placed on leave. She said she was currently at work at the time of the interview. During an interview on 12/21/23 at 9:54 PM, NA D stated no one outside of the HHSC Investigator had interviewed her regarding Resident #1 and LVN A's interaction. She said she did not work on 12/17/23 with LVN A. During an interview on 12/21/23 at 9:58 PM, CNA E stated no one outside of the HHSC Investigator had interviewed her regarding Resident #1 and LVN A's interaction. She said she worked on 12/17/23 with LVN A. During an interview conducted on 12/21/23 at 10:01 PM, CNA F stated no one outside of the HHSC Investigator had interviewed her regarding Resident #1 and LVN A's interaction. She said she worked on 12/17/23 with LVN A. During an interview on 12/21/23 at 10:05 PM, LVN G stated no one outside the HHSC Investigator had interviewed her regarding Resident #1 and LVN A's interaction. She said she worked on 12/17/23 with LVN A. During an interview conducted on 12/22/23 at 3:04 PM, the ADM stated that she did not report the allegations of abuse and did not investigate the claims of abuse because she felt that Family Member B was not saying that she thought that Resident #1 was abused. She stated Family Member B said LVNA A was not speaking directly to Resident #1. She stated that Family Member B said that LVN A redirected her mother. She stated she did not know why Family Member B thought the verbal redirection from LVN A was mean. She stated that she had not spoken with LVN A since the report from Family Member B. She said she had not talked to LVN A because she was asleep. She said LVN A was on duty when the information was reported to her. She stated she did not know why she did not call her (LVN A) when Family Member B reported LVN A was rude to Resident #1. She stated it may have been because it was late. She said that she talked with the staff, and they had not seen anything. She stated she had no witness statements or evidence indicating that she spoke with staff. She also said that during previous safety surveys, Resident #1 had never expressed any concerns about her safety. A record review of text messages provided by Family Member A revealed that on 12/20/23 at 8:13 PM, Family Member B informed the ADM that Sunday (12/17/23), that nurse, which was later identified as LVN A by the ADM, was rude to Resident #1. She expressed that if Resident #1 was in her right mind, Resident #1 would not act as she does. Family Member B said Resident #1 had experience as a certified nurse aide and would have never talked to her patients the way LVN A spoke to Resident #1. Family Member A said Resident #1's heart would have been broken if she was LVN A's CNA because of how she treated Resident #1. Family Member B said she had to hold back, not say anything to LVN A, and focus on taking care of Resident #1. Family Member B said that when she was walking Resident #1 to her room, LVN A stopped her, and LVN A said, [Resident #1] better not have another night like the last few nights. Family Member B said LVN A was upset at Resident #1 and kept saying how mad she was because she had to write a long note about Resident #1 sending a male resident to the female area of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 5 of 6 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 12/22/2023 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility. She said LVN A's tone was an issue and that she had to tune her out because she kept repeating herself. The ADM responded in the text message and stated she would talk with LVN A. Review of facility's policy, Abuse Investigation and Reporting, Revised July 2017, revealed: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Role of the Administrator If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. Role of the Investigator The individual conducting the investigation will at the minimum Interview the person's reporting the incident Interview any witness to the incident Interview the resident Interview staff members on all shifts who have had contact with the resident during the period of the alleged incident Upon conclusion of the investigation, the investigator will record the results of the investigation on approved documentation forms and provide the completed documentation to the administrator. Review of facility's policy, Abuse and Neglect-Clinical Protocol, Revised July 2017, revealed: Cause Identification The staff, with physician's input (as needed), will investigate alleged occurrences of abuse and neglect to clarify what happened and identify possible causes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 6 of 6