Mesquite Village: Untreated Wound Bleeding for Months - TX
The wound, described by staff as "about the size of a quarter," bled repeatedly throughout the resident's stay. Multiple employees witnessed the bleeding but the facility failed to maintain adequate documentation or coordinate consistent treatment.
A certified nursing assistant who worked with Resident #1 told inspectors the tailbone wound "bled a little bit at times" and described seeing it bleed "a couple of times" before the resident's discharge. When the wound bled during showers, she would complete shower sheets and notify nurses to apply cream, but the documentation disappeared into a drawer at the nurses station.
"She stated she was not sure if the nurse managers were aware of his butt wound but the shower sheets were completed and the nurse put them in the drawer at the nurses station," inspectors wrote.
The resident's condition caused him physical discomfort. Former CNA U, who worked at the facility from September 2024 until the resident's discharge, told inspectors that "sometimes Resident #1 was in pain because of the butt wound."
During showers, staff had to modify their care approach because of the wound's sensitivity. The CNA said when bathing the resident, "she would pat the area of his butt really softly" to avoid aggravating the sore.
The wound persisted without healing throughout the resident's stay. The former CNA stated she "did not see Resident #1's butt sore healed" during her entire time caring for him, from September 2024 through his discharge.
Inconsistent wound care compounded the problem. The CNA observed that dressings were applied sporadically - "sometimes Resident #1 did not have a dressing on it and if it drained, a dressing was put on it." She noted that only one nurse, LVN C, consistently provided proper wound treatment after showers.
"She stated she did not see other nurses doing the skin treatments after he showered but LVN C," the inspection report states.
Communication breakdowns prevented proper oversight of the resident's condition. The former CNA described attempting to discuss the wound with nurses but found management unapproachable. She told inspectors that when Director of Nursing O started working at the facility, "he was not too talkative and did not say hello to the CNA's and would just walk by them, so she never talked to him about anything."
The CNA also stated she "did not see ADON G to talk about Resident #1's wound but did talk to the nurses about it," indicating limited access to nursing leadership for wound care concerns.
Licensed nursing staff demonstrated poor knowledge of the resident's condition. LVN N, interviewed about the case, admitted uncertainty about basic details of the wound she was responsible for treating. She "stated Resident #1 had a sore with a dressing on his coccyx and was kind of not sure of the size."
The nurse's lack of awareness extended to specialized care coordination. When asked about wound care consultation, "she stated she was not aware he had a wound care consult," despite the persistent nature of the bleeding sore.
Memory lapses further compromised care continuity. LVN N told inspectors "she forgot because it had been so long ago last year 2024," suggesting inadequate documentation prevented staff from maintaining consistent knowledge of resident conditions.
The facility's shower documentation system created an illusion of proper care while actual wound treatment remained inconsistent. Staff completed required paperwork that was filed away, but the underlying medical issue persisted without resolution.
Multiple staff members witnessed the ongoing bleeding and pain but the facility failed to implement effective treatment protocols or ensure management awareness of the serious wound care needs.
The inspection revealed a pattern of superficial compliance with documentation requirements while actual resident care suffered from poor communication, inconsistent treatment, and inadequate nursing oversight.
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 21, 2026 · Our methodology
Mesquite Village Wellness & Rehabilitation in Mesquite, TX was cited for violations during a health inspection on August 21, 2025.
The wound, described by staff as "about the size of a quarter," bled repeatedly throughout the resident's stay.
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.