Health inspection·November 19, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 09/04/25).*Resident #1's care plan dated 09/2/25 did not address the incident of aggression from 09/03/25 by way of goals and interventions. During an interview on 09/24/25 at 6:57 PM, Resident #1 was unable to participate in an interview as he did not answer any questions related to the incident that occurred on 09/03/25. Resident #2Record review of Resident #2's face sheet, dated 09/24/25, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include Alzheimer's (memory loss), anxiety (increased worry) and major depressive disorder (mood disorder characterized by persistent feelings of sadness). Record review of Resident #2's Comprehensive Minimum Data Set, dated [DATE], revealed the following: *Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's cognition was severely impaired.*Section E did not reveal any coded behaviors.*Section V revealed that Resident #2 did not trigger for CAA #9 Behavioral Symptoms.Record review of Resident #2's Change of Condition Evaluation, dated 09/06/25 revealed:The change of condition identified was other (resident to resident- hit another resident).Findings: No changes noted and the incident had not occurred before.Skin Status Evaluation: No change of condition reported.Vitals Signs were evaluated.Provider Notification and Feedback: clinician notified on 09/06/25 at 11:45 PM, and recommendation of the clinician was to monitor.Resident Representative Notified on 09/06/25 at 11:45 PM. Record review of Resident #2's progress notes, dated 06/23/25-09/24/25, revealed:*09/7/25 at 3:11 AM the ADON documented Resident #2 hit another resident that was watching TV in the dining room. Resident #2 hit another resident twice on the back of the neck and upper back. Both of the residents were separated. Further review of Resident #2's progress notes did not reveal any further incidents of aggression after 09/06/25. Record review of the facility's incident and accident report, dated 09/24/25 revealed:Resident #2 had an incident of resident-to-resident aggression that occurred on 09/06/25. Record review of Resident #2's Q15 minute rounds documentation indicated that he was on 15 minute checks from 09/06/25-09/09/25. Review of Resident #2's care plan, dated 2/5/25 revealed the following:*Resident #2 had a focus with the category behavioral symptoms for having a history of verbal and physical behaviors (initiated 2/11/25; revision 2/11/25). The goal was for Resident #2 to have fewer episodes. Interventions included managing Resident #2's medications as ordered.*Resident #2 care plan did not address the incident of aggression from 09/06/25 by way of goals and interventions. During an interview on 09/24/25 at 6:18 PM, Resident #2 was unable to participate in an interview as he did not answer any questions related to the incident that occurred on 09/06/25. Resident #3Record review of Resident #3's face sheet, dated 09/24/25, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include intermittent explosive disorder (mental disorder characterized by sudden intense outburst of anger), cognitive communication deficit (difficulty communicating), anxiety (increased worry), dementia (memory loss), and major depressive disorder (mood disorder characterized by persistent feelings of sadness). Record review of Resident #3's Comprehensive Minimum Data Set, dated [DATE], revealed the following: *Section V revealed that Resident #3 did not trigger for CAA #9 Behavioral Symptoms. Record review of Resident #3's Quarterly Minimum Data Set, dated [DATE], revealed the following: *Section C Brief Interview for Mental Status score revealed a score of 07, which indicated the resident's cognition was severely impaired.*Section E did not reveal any coded behaviors. Record review of Resident #3's physician orders, dated 09/24/25, revealed the following:*Resident #3 was ordered Valium 2MG for intermittent explosive disorder (Revision Date: 09/16/25 Supply last order date: open).*Resident #3 was ordered Clonazepam 1MG for anxiety, and psychotic disturbance (Revision Date: 09/15/25 end date: 9/9/25).*Resident #3 was ordered Clonazepam .5MG for increased anxiety (Revision Date: 09/09/25; Supply last order date: 9/7/25).*Resident #3 was ordered Clonazepam 1MG for increased behaviors (Revision Date: 09/07/25 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 2 of 8 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 11/19/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Supply last order date: open).Record review of Resident #3's Change of Condition Evaluation, dated 09/07/25 revealed:The change of condition identified was other (resident to resident- hit another resident).Findings: Since the change of condition the conditions have gotten better. Resident #3 was hard of hearing and written communication was noted to help. Resident #3 was placed on 1:1 with medication adjustments. Resident #3 had difficulty hearing others.Skin Status Evaluation: No change of condition reported.Vitals Signs were evaluated.Provider Notification and Feedback: clinician notified on 09/07/25 at 5:00 PM, and recommendation of the clinician was to monitor Q15 and monitor new medication (medication not listed).Resident Representative Notified on 09/07/25 at 5:00 PM. Record review of Resident #3's progress notes, dated 06/23/25-09/24/25, revealed:*09/07/25 at 5:00 PM the LVN B documented Resident #3 was outside with other residents when a female resident became upset with Resident #3 for continually touching her book. It was observed that when the female resident blocked him from touching her book Resident #3 hit her on the shoulder. There were no injuries. The residents were separated and assessed. Resident #3 was extremely hard of hearing, so communication was completed with written instruction to stay away from female residents. Resident #3 voiced understanding. Record review of the facility's incident and accident report, dated 09/24/25 revealed:Resident #3 had an incident of resident-to-resident aggression that occurred on 09/07/25. Record review of Resident #3's Q15 minute rounds documentation indicated that he was on 15 minute checks from 09/07/25-09/09/25. Resident #3's care plan, dated 2/5/25 revealed the following:*Resident #3 had a focus with the category behavioral symptoms for displaying physical behaviors. (initiated 2/11/25; revised 7/01/25) The goal was for Resident #3 to have fewer episodes of the behavior. Interventions included ensuring Resident #3 was removed from the situation, approach in a calm manner, medications adjustments by the provider, and praise any indication of progress/improvement in behavior.*Resident #3's care plan did not address the incident of aggression from 09/07/25 by way of goals and interventions. During an interview on 09/25/25 at 10:40 AM, Resident #3 stated he did not want to talk about his incidents of aggression but that he tried to get along with his peers. He stated he had a hard time hearing and never requested a hearing aid. He stated he had some changes to his medication, but he felt that his medication was working. He stated he had not had any additional incidents of aggression since 09/07/25 and had no intention of causing trouble. During an interview on 9/24/25 at 11:14 AM CNA G stated he had been trained on resident altercation processes after incidents regarding Resident #1, Resident #2, and Resident #3 that occurred on 09/03/25, 09/06/25, and 09/07/25. He reported that the incidents of aggression were isolated and had not happened before the dates of the incidents and since the incident of aggression dates. He reported he had been trained to separate the residents that were involved in a resident-to-resident altercation, protect the residents, implement monitoring for residents involved and report the incident to management immediately. He reported all resident behaviors were manageable. During an interview on 9/24/25 at 12:14 PM the DON stated if the residents made physical contact with one another then staff should separate the residents and start monitoring Q15. She stated there were times where the residents were placed on 1:1 supervision She stated in all three incidents of aggression involving Resident #1 on 09/03/25, Resident #2 on 09/06/25 and Resident #3 on 09/07/25 the staff separated the residents from the other resident or residents involved, implemented Q15 monitoring, assessed all residents involved (no negative findings), notified the resident representatives and doctors. The DON stated all incidents of aggression involving Resident #1, Resident #2, and Resident #3 were isolated events and had not happened before the dates of the incident and had not occurred after the dates of the incident. During an interview on 9/24/25 at 1:33 PM CNA C stated she was present when Resident #3 had his incident of aggression on 09/07/25 and he hit (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 3 of 8 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 11/19/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some two other residents. CNA C stated it was around 4:15 PM and she was preparing for the resident's smoke break. She stated Resident #3 was irritating another resident and when the other resident redirect Resident #3 he responded by hitting her. CNA C stated she immediately stepped in and separated the residents. She stated she called for help and LVN D came, but before LVN B came another resident was speaking up and Resident #3 hit her. She stated LVN B came immediately when she called him. She stated other residents were outside and they were talking to Resident #3 and it did not make the situation better. She stated it happened very fast but there were no injuries. She stated there was no indication that Resident #3 was upset. She stated Resident #3 appeared to be his normal self. She stated she felt that Resident #3 and his behaviors were manageable but on 09/07/25 the other residents were talking to him. She had been trained on the facility's ANE policy and resident altercation process after Resident #1, Resident #2, and Resident #3 that occurred on 09/03/25, 09/06/25, and 09/07/25. She reported that the incidents of aggression were isolated and had not happened before the dates of the incidents and since the incident of aggression date. She reported she had been trained to separate the residents that were involved in a resident-to-resident altercation, protect the residents, implement monitoring for residents involved and report the incident to management immediately. She reported all resident behaviors were manageable. During an interview on 9/24/25 at 3:31 PM the ADON stated she and her staff had been trained that when there was a resident-to-resident altercation they were to separate the residents and then report the incident to management. The ADON stated she was made aware of all three incidents of aggression involving Resident #1 on 09/03/25, Resident #2 on 09/06/25 and Resident #3 on 09/07/25. She stated it was reported to her when the incident occurred on 09/06/25 staff separated the residents, assessed the residents (no negative findings) and notified the doctor and the resident representatives. She stated because of each incident all staff were reeducated and trained on the ANE policy and resident altercations. The staff conducted monitoring Q15 to ensure further incidents did not occur. The ADON stated the resident-to-resident altercations were handled appropriately because the staff responded immediately by separating the residents and reporting.During an interview on 9/24/25 at 3:49 PM LVN D stated he was present for when Resident #3 had his incident of aggression. He stated he could not remember if he heard a commotion or if CNA C called him, but he went to assist, and CNA C had already separated the residents to include Resident #3. He stated Resident #3 placed his hands on another resident's book and when the other resident redirected his hands off her book he hit her. LVN D stated during the same incident another resident was walking by, and Resident #3 hit the other resident. LVN D stated the incident of aggression had never happened before with Resident #3 and the other residents involved. He stated the other residents involved do not have a history of behaviors. He stated he assessed all residents involved and there were no negative findings. LVN D stated Resident #3 was placed on monitoring Q15. He stated there were no further incidents. He had been trained on the facility's ANE policy and resident altercation process after Resident #1, Resident #2, and Resident #3 that occurred on 09/03/25, 09/06/25, and 09/07/25. He reported that the incidents of aggression were isolated and had not happened before the date of the incidents and since the incident of aggression date. He reported he had been trained to separate the residents that were involved in a resident-to-resident altercation, protect the residents, implement monitoring for residents involved and report the incident to management immediately. He reported all resident behaviors were manageable and he did not report any concerns with managing resident behaviors. During an interview on 9/24/25 at 4:20 PM LVN E stated she was present when Resident #2 had his incident of aggression on 09/06/25. She stated she was seated at the nurse's station and heard skin contact like a slapping noise. She stated she and CNA K immediately separated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 4 of 8 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 11/19/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #2 from the other resident. She stated she assessed both residents and there were no negative findings. She stated Resident #2 had never had an incident of aggression with other residents and this was isolated. She stated Resident #2 could get aggressive but not towards residents. She stated Resident #2 would be aggressive during resident care. She stated for example he would grab the doors, chairs and items around when staff attempt to lay him down. She had been trained on the facility's ANE policy and resident altercation process after Resident #1, Resident #2, and Resident #3 that occurred on 09/03/25, 09/06/25, and 09/07/25. She reported that the incidents of aggression were isolated and had not happened before the date of the incidents and since the incident of aggression date. During an interview on 9/24/25 at 5:21 PM CNA F stated she did observe/ hear the indent of aggression involving Resident #2 on 09/06/25 but heard a loud slapping noise. She stated she went and assisted the nurse (LVN E) with the residents. She stated she was at the nurse's station completing documentation when the incident happened. She stated they intervened immediately and monitored the residents for the remainder of the shift. She stated there were no further incidents. She stated Resident #2 did not ever have any incidents of aggression and this was abnormal for him. She stated LVN C assessed them and there were no negative findings.During an interview on 9/24/25 at 6:20 PM the MDS Coordinator stated the incident of aggression that occurred on 09/03/25 was discussed in the morning meeting and should have been revised. She stated the incident of aggression involving Resident #2 also would have been discussed in the morning meeting because it occurred on 09/06/25. She stated Resident #2's aggression was normal behavior for him. She stated the incident of aggression that occurred on 09/07/25 involving Resident #3 also would have been discussed in the morning meeting. She stated Resident #3 had some medication changes and since the change had experienced an increased in behavior. She stated none of the incidents of aggression that occurred involving Resident #1, Resident #2 and Resident #3 had been reflected in their care plans. She stated the care plan was a way that staff could see what was needed to care for the residents. She stated the care plan was updated by the nursing staff, the SW, activities, dietary, therapy and her. She stated they go over the care plan in daily meetings by reviewing incidents under risk management. She stated they also go over incidents weekly in the Standards of Care Meeting (SOCs). She stated if there was an incident she would open the system up so that the correct discipline can make changes. She stated if she was not present at work then the DON or ADON can also perform the revisions. She stated the care plan was used by all staff. She stated the clinical staff such as the aides can view the care plan contents in the care plan in the POCs located in the EMR. The MDS Coordinator stated she was familiar with the care plan policy. She stated if a CAA was triggered in the MDS then it should be care planned unless otherwise indicated. She stated all behaviors should be care planned. She stated Resident #1 triggered for behavior, but it was the behavior for wandering/elopement. She stated Resident #1 after his incident of aggression should have had his care planned updated/ revised for the behavior (aggression). The MDS Coordinator stated the potential negative outcome for not care planning the incidents of aggression was that additional incidents could occur. She stated the CNAs, and the nurse knew to separate the residents and implement monitoring Q15 even if the incident was not care planned because it was a part of the facility process to sperate the residents and start monitoring. She stated she was unsure if the staff would know specific goals for the residents without the care plan being revised. She stated the system to monitor the creation, implementation and revision of care plans was when there was an incident that occurred, they reviewed daily in the risk management portion of their daily meeting. She stated they also reviewed any incidents in their weekly meeting. She stated once the incidents were discussed she would open the area up in the care plan and the respective role/discipline (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 5 of 8 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 11/19/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some would complete the care plan. She stated the overall goal was to keep the residents safe from harm. The MDS Coordinator stated that the DON and ADON would have been the disciplines responsible for the revisions. The MDS Coordinator stated outside of the daily risk management or morning meetings, and at the weekly SOC meeting she was unsure if there were any additional processes to help monitor the creation, implementation and revision of care plans. The MDS Coordinator stated she expected the care plans for the residents to be revised after she opened up it up in the EMR and when there was incident involving the residents. She stated she would at least allow for two weeks if there was an incident for the care plan to be revised. She stated although the policy addressed the standard times for when the care plan should be revised (48 hours after admission, 7 days after admission, 21 days after admission, quarterly and annually), the care plan should be revised after there was a resident-to-resident altercation. The MDS Coordinator stated she was responsible for care plan revisions, and she was not available then the respective department would be responsible. She stated she was not unavailable for any of the days in which the incidents of aggression occurred involving Resident #1, Resident #2, and Resident #3. She stated the reason the care plan revisions were not completed was because she did not remember going over the incidents as thoroughly as they normally do. She stated she was unsure why they did not go over the incidents of aggression as thoroughly as they normally do. During an interview on 9/25/25 at 8:59 AM ADON stated a care plan was a plan in which stated how they were going to take care of the residents in the facility. She stated they have to keep the care plan updated for all of the care that they are providing for the residents. She stated all the staff used the care plan. She stated the nurses and aides needed to know how they were going to care for the residents. She stated all staff had access to the care plan. She stated regarding behaviors the care plan showed how staff were going to treat them and how they would assist with the behavior. She stated the information from the care plan was communicated from the DON and her verbally to staff. She stated all information in the care plan can be viewed by the aides in the EMR under the POCs. She stated the purpose of updating the care plan was that it would be reflected in the POCs and that way the aides would know how to handle resident behaviors. She stated the revision could play a part in reducing resident behaviors and preventing them from happening again. The ADON stated she was familiar with the care plan policy. She stated she had never revised a care plan immediately after an incident but that the care plan should be revised if there was an incident of aggression. The ADON stated the potential negative outcome for not revising care plans was that the resident behavior would not get better and the negative behavior would continue. She stated she was unaware that the revisions on all three incidents of aggression had not been completed. She stated the facility's system to create, implement, monitor and revise resident care plans was the revisions were conducted in the daily meetings and the weekly SOC meetings. She stated revisions would also be conducted during the monthly care plan meetings that occurred on a quarterly basis. She stated she had been trained on care plan revisions. She explained the company that was over the facility was very proactive about care plans and the system to implement and revise. She stated that care plans should be revised as incidents were happening and if there were changes with the residents. She stated the MDS Coordinator was responsible for revisions and that she normally completed the revisions for the resident care plan. The ADON stated she did not have a reason why the care plan revisions were not made. She stated she remembered discussing the incidents of aggression in their morning meetings. During an interview on 9/25/25 at 9:30 AM the ADM stated the care plan was the plan of care for the residents. She stated the care plan laid out care for the residents. She stated all the staff in all disciplines could refer to the care plan as it was a tool to use. She stated residents that had behaviors were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 6 of 8 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 11/19/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some reflected in the MDS and it would trigger the CAAs to be reflected in the care plan. The ADM stated care planning behaviors helped mitigate the behaviors for the best outcome of the behavior. The ADM stated all staff used the care plan. The ADM stated the aides could access the care plan contents through the POCs, but all other disciplines can view the care plan in its entirety. The ADM stated she was familiar with the care plan. She stated their facility policy did not spell out the expectation regarding care revisions. She stated the policy had a minimum requirement to update the care plan on a quarterly basis. She stated the facility process to monitor care plan revisions was during the daily meetings they (the IDT) discuss risk management and the incidents in their entirety. She stated if there was an altercation they would discuss in their morning meeting because this would essentially be a self-report. She stated when they discussed the incident it was the opportunity to ensure that the progress notes were done, care plan was revised, and interventions implemented. She stated quarterly revisions were the minimum expectation according to the facility policy. She stated ideally and her expectation was for the care plan was revised at the time of risk management discussion daily. She stated standard interventions would be what the facility staff did. She stated the staff separated the residents and implemented monitoring Q15. She stated interventions were implemented and discussed but were not updated in the care plan. She stated that for the residents involved in the incidents of aggression they (the IDT) discussed environmental factors, medication changes, and psychiatric supervision. The ADM stated the incidents of aggression were isolated and not ongoing for all three residents (Resident #1, Resident #2, and Resident #3). The ADM stated the potential negative outcome for not revising resident care plans after a resident-to-resident altercations was the staff may not know how to respond or intervene with said resident because the care plan was used as a tool. She stated she was unaware that the revisions had not been made. She stated the system to monitor a resident care plan was the daily meetings where they discussed risk management, weekly SOC meetings, quarterly and annual resident care plan meetings. The ADM stated they were taking the missed revisions for Resident #1, Resident #2 and Resident #3 as an opportunity to grow. She stated she and her staff had been trained on care plan and care plan revisions. She stated the new corporate took over in February 2025 and they received training from February 2025 by the new management company. She stated the best practice would be that the care plan was revised as part of the follow-up to resident incidents involved. She stated to follow policy then the care plan would be updated quarterly. She stated the IDT was responsible for revising the care plan. She stated regarding behaviors the SW would have been responsible. The ADM stated the reason the SW did not complete the care plans revisions could have been because she was new and prior to coming to the facility she had not completed the care plans. The ADM stated the MDS Coordinator was the keeper of the entire care plan and should have notified the SW. During an interview on 9/25/25 at 10:03 AM the DON stated the care plan was a guide that contained the plan of care for each resident. The DON stated the care plan contained the needs and the way to care for each resident. The DON stated the care plan specified the needs of each resident. The DON stated all staff have access to the care plan to use depending on their discipline. The DON said when they identify a behavior, they care planned the incident so that staff know how to approach the situation. She stated depending on the role that would determine how they (the staff) were able to view the information from the care plan. She stated once the information was placed in the care plan then the appropriate portions would be tasked out to the clinical staff such as the aides. The DON stated even if the care plan was not revised, she felt that the facility's education system was strong enough to educate the staff on facility expectations. The DON stated she felt the staff were aware of the residents' personal interventions. The DON stated she was familiar with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676163 If continuation sheet Page 7 of 8 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 11/19/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete the facility care plan policy. She stated although they discussed incidents involving residents daily in risk management the care plan revisions for Resident #1, Resident #2, and Resident #3 fell through the cracks. The DON stated additionally they monitored care plan revisions through weekly SOC meetings that occur weekly (Wednesday) at 1:00 PM. She stated the potential negative outcome for not revising care plan meetings was the staff may be unaware of incidents that happened or interventions that were needed. The DON stated staff could miss resident care needs. The DON stated she was unaware that the care plan revisions for all three incidents of aggression had not been completed. She stated the system to monitor care plan revisions was that all residents were updated quarterly and annually. She stated she had been trained about a couple of weeks ago and again on 09/25/25. She stated she had been trained by her corporate management team that all incidents should be addressed by the IDT. She stated all disciplines were involved but that the SW would address chronic issues and the clinical team would address acute issues. She stated the MDS coordinator was responsible for care plan revisions and that they all review anything that fell under their discipline. The DON stated she did not have an excusable reason why the care plan revisions were not completed.During an interview on 9/25/25 at 10:21 AM the SW stated a care plan was a plan of care for each resident. She stated it told staff what the plan of care was for each resident so that staff could provide appropriate care for each resident. The SW stated behaviors should be care planned and revised so that all staff were aware of resident behaviors. She stated care planning behaviors would help create interventions to help address resident behavior. She stated care planning and revising resident behaviors would also assist with making necessary referrals that the residents may need. The SW stated leadership, the facility aides, nurses and the entire IDT used the care plan to provide care for the residents. The SW stated the clinical staff also received verbal instruction from the nurses about the residents' interventions and goals. The SW stated she was familiar with the facility's care plan policy. She stated the revised the care plan on a quarterly basis per the facility policy. The SW stated this did not mean they would not look at the care plan before the quarter or annual because ideally, they should revise the care plan anytime an event or incident occurred. The SW stated the potential negative outcome of not revising the care plan was that the resident may not receive appropriate care and what they need to address the situation identified. She stated she was unaware care plan revisions had not been completed. She stated she remember discussing the incidents of aggression involving Resident #1, Resident #2, and Resident #3 in morning meeting, b Event ID: Facility ID: 676163 If continuation sheet Page 8 of 8