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Deficiency Records for Highland Manor of Mesquite Rehabilitation LLC
A list of the most recent deficiencies for Highland Manor of Mesquite Rehabilitation LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Highland Manor of Mesquite Rehabilitation LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-04-25 | 2024-06-08 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-04-25 | 2024-06-08 | N |
| Respond appropriately to all alleged violations. | Health | 2024-04-25 | 2024-06-08 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2024-04-25 | 2024-06-08 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2024-04-25 | 2024-06-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-04-25 | 2024-06-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-04-18 | 2024-06-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-04-18 | 2024-06-08 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-04-18 | 2024-06-08 | N |
| Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | Health | 2023-03-09 | 2023-05-18 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-03-09 | 2023-05-18 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-03-09 | 2023-05-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-03-09 | 2023-05-18 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-03-09 | 2023-05-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-09 | 2023-05-18 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-03-09 | 2023-05-18 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-03-09 | 2023-05-18 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-03-16 | 2023-04-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-16 | 2023-04-13 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-03-16 | 2023-04-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-16 | 2023-04-13 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-05-20 | 2022-06-30 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-05-20 | 2022-06-14 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-05-20 | 2022-06-09 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-05-20 | 2022-06-09 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2022-05-20 | 2022-06-09 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-05-20 | 2022-06-09 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-05-20 | 2022-06-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-20 | 2022-06-09 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-05-20 | 2022-06-09 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-05-20 | 2022-06-09 | N |
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