Health inspection·May 3, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3. Review of Resident #15's quarterly MDS assessment, dated 03/29/2023, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with the following diagnosis: Alzheimer's. An observation and interview on 05/01/23 at 11:05 a.m., revealed Resident #15 was standing behind a wheelchair in the hallway, that right arm rest was cracked jagged edges on the wheelchair with the interior padding exposed. Resident #15 stated that the wheelchair was not her wheelchair and walked off down the hallway. 4. Review of Resident #23's quarterly MDS assessment, dated 03/29/2023, reflected he was a [AGE] year-old male admitted to the facility on [DATE], with the following diagnoses: difficulty in walking, lack of coordination, and muscle weakness. Resident #23 was severely impaired for decision making. Review of the Resident #23's plan of care dated 03/29/20/23 with updates reflected goals and approaches to include wheelchair mobility. An observation on 05/01/23 at 12:15 p.m., revealed Resident #23's right side and left side arm rest on the wheelchair was cracked with jagged edges, and the interior padding was exposed. The arm pads were not appropriately clean, they were stained with a dark substance. 5. Review of Resident #44's admission MDS assessment, dated 04/26/2023, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with the following diagnoses: chronic obstructive pulmonary disease (difficulty breathing), and rhabdomyolysis ( a condition that causes muscle breakdown). Review of the Resident #44's plan of care dated 04/22/20/23 with updates reflected goals and approaches to include wheelchair mobility. An observation on 05/01/23 at 10:00 a.m., revealed Resident #44's right side and left side arm rest on the wheelchair was cracked with jagged edges, and the interior padding was exposed. The arm rests had a dark dried substance on the top. 6. Review of Resident #99's admission MDS assessment, dated 03/31/2023, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with the following diagnoses: Osteoarthritis of both knees, and repeated falls. Resident #99 was severely impaired for decision making. Review of the Resident #99's plan of care dated 04/20/20/23 with updates reflected goals and approaches to include wheelchair mobility. An observation on 05/01/23 at 10:15 a.m., revealed Resident #99's right side arm rest on the wheelchair was cracked with jagged edges, and the interior padding was exposed. The arm rest could not be cleaned. 7. Review of Resident #100's admission MDS assessment, dated 04/13/2023, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with the following diagnoses: Muscle weakness and reduced mobility. Resident #100 was severely impaired for decision making. Review of the Resident #100's plan of care dated 04/20/20/23 with updates reflected goals and approaches to include wheelchair mobility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676480 If continuation sheet Page 2 of 11 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 676480 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesquite Village Wellness & Rehabilitation 825 W. Kearney Street Mesquite, TX 75149 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 Residents Affected - Some An observation on 05/01/23 at 9:45 a.m., revealed Resident #100's right side arm rest on the wheelchair was cracked jagged edges, and the interior padding was exposed with [duct-tape] over the right-side arm rest. The duct tape had a dark gummy substance stuck to it. Interview on 05/02/23 at 12:55 p.m., LVN A revealed if something was broken or needed to be repaired, like a wheelchair he would just tell the maintenance man. LVN A stated the maintenance man is usually here and if he was not then he would tell the DON or ADON about the need of repair. LVN A stated that there was no logbook to document in for maintenance repairs and there was no communication system for repairs. The LVN stated the maintenance man repaired the wheelchairs. LVN A was not aware of any wheelchairs requiring repair. Interview on 05/02/23 at 1:24 p.m., CNA B revealed if something was broken, she would tell the maintenance director or the nurse. CNA B sad she was not aware of any place to document the need for something to be repaired if was broken. CNA B sated she was not aware of any wheelchairs that required repair. Interview on 05/02/23 at 2:00 p.m., the Maintenance Director revealed the staff was to use TELS (computer information system for communicating with maintenance) to communicate the need for repair in the facility, but most of the staff still just stop me and tell me what needs to be fixed. The Maintenance Director said when this happens, I tell the staff members to put it in TELS, so I fix what is in TELS. The maintenance director said he was responsible for the repairs to the wheelchairs; the staff had not communicated to him that there was a need of repair to the wheelchairs. Interview on 05/02/23 at 2:13 p.m., the DON revealed the facility staff was supposed to use TELS to communicate the need of repair for anything in the facility, including wheelchairs. The DON stated that the staff stop her and tell her about facility and maintenance needs. The staff has bee told they are supposed to use TELS, but I am not sure if they really know how to use it, I do not really know how to use the system. The DON said she was aware that the Maintenance director was supposed to repair, wheelchairs. The DON said she was not aware of any wheelchairs that needed repair. Interview on 05/02/23 at 3:20 p.m., the Maintenance Director revealed, when he approached the surveyor and stated now that he was aware of the wheelchair problem, he had made rounds and identified all the wheelchair that required repair and had ordered new arm rest for them, and he had a reminder in TELs now so he would not forget to make rounds and check the wheelchairs in the future. Interview on 05/03/23 at 3:00 p.m., the Administrator revealed that the residents did require wheelchairs that were good repair, and she knew that if the resident did not it could affect their ability to have mobility. Review of the TELs log report reflected for the months of March and April, of 2023, there was no documentation related to the condition of the wheelchairs. Review of facility's policy Assistive Devices and Equipment, dated January 2020 reflected Our facility maintains equipment for residents 1. Certain devices and equipment that assist with resident mobility, safety and independence are provided for residents .these may include .mobility devices (wheelchairs ) 6.device condition-devices and equipment are maintained on schedule .defective or worn devices are discarded or repaired FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676480 If continuation sheet Page 3 of 11 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 676480 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesquite Village Wellness & Rehabilitation 825 W. Kearney Street Mesquite, TX 75149 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to review and revise the person-centered care plan to reflect the current condition for 2 (Residents #8 and #27) of 6 residents reviewed for care plan revisions. The facility failed to ensure Resident #8's care plan was updated to reflect her desire for positioning while eating and taking medications. The facility failed to ensure Resident #27's care plan was updated to reflect his refusal for treatment concerning his diabetic ulcers on his feet. This deficient practice could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. Findings included: Record review of Resident #8's face sheet dated 05/02/2023, indicated a [AGE] year-old female who initially admitted on [DATE] and readmitted on [DATE] with diagnoses which included Multiple Sclerosis (a disease of the muscles and nerves) and atherosclerotic heart disease (a disease of the heart and the heart valves being stopped up). Record review of Resident #8's quarterly MDS dated [DATE], indicated she was always understood and always understood others. Resident #8 had a BIMS of 12 (Indicated she is moderately impaired for decision making). Section G reflected Resident #8 required no assistance to eat. Record review of Resident #8's comprehensive care plan dated 12/02/2022 reflected a potential swallowing problem but failed to indicate the position for eating and taking medications that the resident preferred. Observation on 05/01/23 at 12:15 p.m., revealed Resident #8 lying in her bed with the head of the bed no greater than 30 degrees eating her lunch that was placed on the left side of the bed. Resident #8 stated that she always lies in bed with her head this low or lower and eats, that is what she prefers. Observation on 05/02/23 at 7:41 a.m. with MA E revealed Resident #8 taking her medications lying on her side with the head of the bed lower than 30 degrees. MA E stated this was how she always takes her morning medications, Resident #8 said yes it was that what I want. Record review of Resident #27's face sheet dated 05/02/2023, indicated a [AGE] year-old male who initially admitted on [DATE] and readmitted on [DATE] with diagnoses which included Diabetes Mellitus (inability to control blood sugar), heart disease, and hypertension (elevated blood pressure). Record review of Resident #27's quarterly MDS dated [DATE], indicated he was always understood and always understood others. Resident #27 had a BIMS of 13 (indicated he had normal cognitive functioning). Record review of Resident #27's comprehensive care plan dated 07/14/2022, with revisions on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676480 If continuation sheet Page 4 of 11 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 676480 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesquite Village Wellness & Rehabilitation 825 W. Kearney Street Mesquite, TX 75149 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 0657 Level of Harm - Minimal harm or potential for actual harm 09/28/22, and 03/17/23 reflected a diabetic ulcer but failed to indicate the refusal of the resident to wear podus boots and refusal to wear appropriate socks that prevent edema to the legs. Review of the Physician orders dated 03/2023 reflected a physician order dated 03/21/23 Podus Boots to bilateral (both) feet while in bed. Residents Affected - Few Observation and interview on 05/01/23 at 11:00 a.m., revealed Resident #27 during wound care for his diabetic ulcers. The resident was wearing socks that were to his knees. LVN F stated to resident you are supposed to wear your low socks, the resident said he would not wear them, he liked these socks. LVN F stated you are supposed to wear your podus boots (pressure relieving boots) when you are in the bed also, the resident replied, I will not wear those things, I hate them. During an interview on 05/02/2023 at 2:00 p.m., the DON stated there was no MDS nurse working at the facility at this time. The DON stated the facility was still having the care plan meetings, and she was updating the care plans. The DON stated she was aware the care plans were not resident specific, as the MDS nurse that was here was not doing that, she [previous MDS nurse] did not think it was necessary. The DON stated this could be a problem for the residents, their desires might not be followed and if you had a new nurse then they would not know how to care for the residents. The DON was not aware that Resident #8 and #27's plan of care was not specific to their needs and desires. During an interview on 05/03/2023 at 2:56 p.m., the Administrator said she expected Resident #8 and #27's care plan to reflect the desired care of the residents. The Administrator said the care plan should reflect a picture of the resident's care needs. The Administrator said the nursing managers and the MDS nurse, were responsible for updating and monitoring the care plan for needed revisions. Record review of the policy and procedure Care Plans, Comprehensive Person-Centered dated March 2022 reflected: A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident . 4. Each resident's comprehensive person-centered care plan is consistent with the resident's' rights to participate in the development and implementation of his or her plan of care, including the right to .d. request revisions to the plan of care; e. participate in establishing the expected goals and outcomes of care; f. participate in determining the type, amount, frequency, and duration of care; . 11. Assessments for resident are ongoing and care plans are revised as information about the residents and the residents' condition change . 12. The interdisciplinary team reviews and updates the care plan . b. when the desired outcome is not met FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676480 If continuation sheet Page 5 of 11 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 676480 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesquite Village Wellness & Rehabilitation 825 W. Kearney Street Mesquite, TX 75149 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for three residents (Residents #17, #38 and #148) of thirteen residents reviewed for palatable food. Residents Affected - Some The facility failed to provide palatable food served at an appetizing temperature to residents who complained the food was cold or not hot during breakfast on 5/1/23 and 5/2/23. This failure could place residents who ate food from the kitchen at risk for weight loss, altered nutritional status and diminished quality of life. Findings included: Review of the facility's temperature log dated 5/2/23 for the breakfast meal revealed that the temperature for eggs was recorded at 179 degrees, the temperature for oatmeal was left blank. In an interview with DA C on 5/2/23 at 11:20 AM, DA C stated that she had forgotten to write the temperature for the oatmeal that morning but thought that it may have been around 198 degrees. She stated that food should be served hot so that residents enjoyed eating the food. In an interview with Resident #17 on 5/1/23 at 10:50 AM, Resident #17 revealed that she generally liked the food at the facility, but that her breakfast was always cold. In an interview with Resident #38 on 5/1/23 at 3:03 PM, Resident #38 revealed that the breakfast would often be served cold, especially the eggs. In an observation on 5/02/23 at 8:08 AM it was observed that the cart containing breakfast trays for residents' rooms was brought to the first hall and all trays had been served by 8:10 AM. In an observation on 5/2/23 at 8:17 AM, the second hall breakfast cart was delivered to the second hall, all breakfast trays were observed to be delivered to the residents' rooms at 8:22 AM. A test tray for the survey team was taken from the second hall breakfast cart at 8:23 AM. In an observation and interview with DON on 5/2/23 at 8:23 AM, the test breakfast tray from the second hall cart was tasted by the surveyors and the DON. The tasting revealed that the scrambled eggs were cold on the edges and tepid in the middle, the toast was found to be cold, and the oatmeal was found to be cold. DON stated that the breakfast food from the test tray was cold and did not taste good. In a private interview with a group of ten residents on 5/2/23 at 11:20 AM, the ten residents all revealed to the surveyor that the food was good at lunch and dinner and was served at a good temperature, but that breakfast was always served cold whether they were served in the dining room or in their rooms. The ten residents all revealed that the eggs and oatmeal were always cold. In an interview with Resident #148 on 5/3/23 at 10:20 AM, Resident #148 revealed that the breakfast was always cold and that she generally waited for lunch and dinner to really eat. A review of the facility policy entitled Test Trays, Policy Number 10.004 and dated 2018 revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676480 If continuation sheet Page 6 of 11 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 676480 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesquite Village Wellness & Rehabilitation 825 W. Kearney Street Mesquite, TX 75149 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 0804 Level of Harm - Minimal harm or potential for actual harm that under the heading Policy it stated that, The facility recognizes the importance of routine assurance monitoring to ensure that its residents are provided food that is appealing, palatable and served at the correct temperatures. Under the heading Procedure' the policy stated that, .evaluation will be conducted at each meal to ensure that food temperatures, portion sizes and diet orders are followed. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676480 If continuation sheet Page 7 of 11 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 676480 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesquite Village Wellness & Rehabilitation 825 W. Kearney Street Mesquite, TX 75149 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews and record review the facility failed to store, distribute, and serve food in accordance with professional standards for food safety in the facilities only kitchen. Residents Affected - Some The facility failed to ensure food items past their expiration date were discarded. The facility failed to ensure different types of thawing meats were kept separate to reduce the risk of cross contamination. These failures could place residents at risk for food-borne illness. Findings include: In an observation on 5/1/23 at 10:30 AM several containers of food were stored on the shelves of the walk-in refrigerator, there were a container of pineapple bits dated 4/17/23, a container of applesauce dated 4/18/23, a zip-lock bag containing what appeared to be sausage chunks with no date, a container of tomato soup dated 4/18, and a container of peaches dated 3/25/23. In an observation on 5/1/23 at 10:32 AM a large stainless-steel container was discovered on the bottom shelf of the walk-in refrigerator. The container was observed to have a large ham, a large bag of premade beef/pork meatballs, a large Ziplock bag containing raw ground beef, and another bag containing a turkey breast. In an interview with DM C on 5/02/23 at 8:17 AM, DM C stated that all of the expired food items that were in the walk-in refrigerator the previous day had been discarded. She stated that leftover foods should be discarded after 72 hours from the time the food was placed into the refrigerator and that if residents consumed leftovers that were past their discard date the residents could become ill. In an interview with DA D on 5/02/23 at 11:00 AM, DA D stated that leftover foods had to be dated with the date that it was put into the walk-in refrigerated space. DA D stated that all leftover foods had to be discarded after 72 hours and that if residents ate expired foods, it could cause the residents to become sick. In an interview with DON on 5/03/23 at 2:07 PM, DON stated that if foods were served to residents that were past their respective expiration dates the residents could possibly contract a food borne illness. Review of the facility's policy dated 2018 entitled Food Storage, policy number 03.003, page 2 , section 2 entitled Refrigerators, section e stated that Use all leftovers within 72 hours. Discard items that are over 72 hours old. section f stated that, Store raw meats and eggs on the bottom shelf to prevent contamination of other foods. To avoid cross-contamination, store raw or uncooked food and produce away from and below prepared or ready-to-eat foods. The Food and Drug Administration Food Code dated 2017 reflected, 3-305.11 Food Storage. (A) .food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination .(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676480 If continuation sheet Page 8 of 11 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 676480 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesquite Village Wellness & Rehabilitation 825 W. Kearney Street Mesquite, TX 75149 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . Date marking is the mechanism by which the Food Code requires active managerial control of the temperature and time combinations for cold holding. Industry must implement a system of identifying the date or day by which the food must be consumed, sold, or discarded. Event ID: Facility ID: 676480 If continuation sheet Page 9 of 11 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 676480 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesquite Village Wellness & Rehabilitation 825 W. Kearney Street Mesquite, TX 75149 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for one (400 Hall) of two halls reviewed for environment. The facility failed to ensure windows, furniture, beds, were in good repair for Rooms #411, #409, #405, #408, and the nurse's station. This failure could affect residents and the staff by placing them at risk for diminished quality of life due to the lack of a well-kept environment. Findings included: An observation on 05/08/19 at 07:00 a.m., revealed room [ROOM NUMBER]'s windowsill had wood chipping from the windowsill, and the paint is peeling off halfway across the top and bottom of the window. An observation and interview on 05/02/23 at 7:05 a.m., revealed room [ROOM NUMBER]'s the bed on the B side of the room had a foot board that was on the bed crocked and the side of the foot board was cracked. Resident #19 stated that she felt like she was titling to the side when she looks down there, the resident stated she had not told anyone about the end of her bed, she thought it was up to the facility to see it was crooked and fix it. An observation on 05/02/23 at 7:15 a.m., revealed room [ROOM NUMBER] A the overbed table had all the veneer missing from around the entire edge that surrounds the overbed table. An observation on 05/02/23 at 7:30 a.m., revealed room [ROOM NUMBER] the chest of drawers on the right side of the wall next to the bathroom door had the veneer missing between the first drawer and the second drawer. An observation on 05/02/23 at 8:06 a.m., revealed the only nurse's station in the facility had the Formica (desk top cover) with large areas broken off on the edge with sharp edges along the entire edge of the nurse's station. Interview on 05/02/23 at 12:55 p.m., LVN A revealed if something was broken or needed to be repaired, he would just tell the maintenance man. LVN A stated the maintenance man is usually here and if he was not then he would tell the DON or ADON about the need of repair. LVN A stated that there was no logbook to document in for maintenance repairs and there was no communication system for repairs. Interview on 05/02/23 at 2:00 p.m., the Maintenance Director revealed the staff was to use TELS (computer information system for communicating with maintenance) to communicate the need for repair in the facility, but most of the staff still just stop me and tell me what needs to be fixed. The Maintenance Director said when this happens, I tell the staff member to put it in TELS, so I fix what is in TELS. The maintenance director said he was responsible for the repairs. Interview on 05/02/23 at 2:13 p.m. with the DON revealed the facility staff was supposed to use TELS to communicate the need of repair for anything in the facility, including wheelchairs. The DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676480 If continuation sheet Page 10 of 11 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 676480 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesquite Village Wellness & Rehabilitation 825 W. Kearney Street Mesquite, TX 75149 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete stated that the staff stop her and tell her about facility and maintenance needs. The staff has been told they are supposed to use TELS, but I am not sure if they really know how to use it, I do not really know how to use the system. Interview on 05/03/23 at 4:00 p.m., the Regional Director of Operations revealed the facility had no policy and procedure for physical environment. He stated they use TELS for guidance on repairs and communication. Event ID: Facility ID: 676480 If continuation sheet Page 11 of 11