Mesquite Village: Pressure Injury Care Plan Failures - TX
The resident developed the pressure injury sometime in 2024, but Mesquite Village Wellness & Rehabilitation failed to add the diagnosis to his care plan or inform staff about treatment orders, according to a federal inspection completed in August.
Multiple employees told inspectors they remembered seeing the wound but had no guidance on how to care for it.
CNA R described the injury during an August 20 interview as "a sore on his butt more like circular and sometime would see just a little blood coming from it last year 2024." She said she remembered the resident and his condition.
Another certified nursing assistant who worked at the facility from September 2024 until the resident's discharge said she noticed the wound when she started working there. Former CNA U told inspectors during an August 22 interview that she observed Resident #1's wound throughout her employment.
The facility's own policy requires care plans to be updated within 14 days of any new diagnosis. But months passed without staff creating a treatment plan for the pressure injury.
When inspectors asked the wound care nurse about the resident's condition, she said she forgot about it "because it had been so long ago last year 2024." The nurse told investigators during an August 20 interview that she was not aware the resident had a wound care consult ordered by physicians.
This lack of awareness had serious implications for the resident's health and safety.
MDS Coordinator P explained to inspectors that without proper care planning, "the resident could have a change of condition and need to go to the hospital or get infections." She warned that residents "might receive improper care, not get the right treatment for skin issue" when diagnoses aren't properly documented and care planned.
The MDS coordinator said she wasn't sure why the pressure injury diagnosis was never added to the care plan, noting she wasn't in that position when the wound developed. She told inspectors during an August 20 interview that she typically reviews five residents' documentation daily using a calendar system, checking nurses' notes, doctor's orders, hospital records and psychiatric records for any new additions to residents' electronic medical records.
For new diagnoses, she said she would "create a care plan and discuss in the IDT meeting" with the interdisciplinary team. But this process never happened for Resident #1's pressure injury.
The administrator confirmed during an August 21 interview that the MDS coordinator "was responsible for ensuring medical records were accurate and care plans are updated." She reiterated that facility policy required new diagnoses to be added to care plans within 14 days.
The facility's Care Plan Policy, revised in March 2022, states that "the Interdisciplinary team is responsible for the development of the care plan" and that "comprehensive person centered care plans are based on resident assessments and developed by an interdisciplinary team."
But for Resident #1, this policy wasn't followed. His pressure injury went without a care plan from the time it developed in 2024 until his discharge, leaving nursing staff to provide care without proper guidance or awareness of physician orders.
The breakdown in communication meant that while doctors had ordered wound care consultations, the nursing staff responsible for daily care remained unaware of these orders. The wound care nurse's admission that she forgot about the resident's condition highlights the systemic failure to track and treat his injury properly.
Federal inspectors cited the facility for failing to ensure that care plans were developed according to required timeframes and criteria. The violation affected multiple residents, though Resident #1's case provided the clearest example of how the facility's failures could impact patient care.
The resident's circular wound continued to bleed intermittently while staff worked without proper treatment protocols. His case illustrates how administrative failures in care planning can translate directly into inadequate medical care for vulnerable nursing home residents.
Despite facility policies designed to prevent such oversights, Resident #1 lived with an untreated pressure injury while his caregivers remained unaware of doctor's orders that could have improved his condition.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mesquite Village Wellness & Rehabilitation from 2025-08-21 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Mesquite Village Wellness & Rehabilitation in Mesquite, TX was cited for violations during a health inspection on August 21, 2025.
Multiple employees told inspectors they remembered seeing the wound but had no guidance on how to care for it.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.