Sante Of Mesa

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, review of records and review of policies and procedures, the facility failed to ensure that services met professional standards of quality by failing to administer medications according to physician ordered parameters for one of five sampled residents (#4). The deficient practice could result in residents to receiving medications that did not meet the provider parameters. Resident #4 was admitted on [DATE] with diagnoses that included displaced trimalleolar fracture of right lower leg, contusion of lower back and pelvis, anxiety disorder, type 2 diabetes with chronic kidney disease, morbid obesity, and major depressive disorder.A care plan initiated on July 12, 2025 revealed the following areas of focus:Hypertension related to CHF (congestive heart failure) and kidney disease with interventions, initiated July 12, 2025, that included to give anti-hypertensive medications as ordered.Potential for actual alteration in comfort/pain related to recent hospitalization, initiated on July 12,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to ensure that one resident (# 634) was properly informed by not implementing a password protocol for visitation.Based on clinical record review, interviews, and facility documentation and facility documentation and policy, the facility failed to ensure that the facility implemented a password protocol to protect one resident (# 634) from harm. The sample size was four residents. This deficient practice could result in residents being further victimized. Findings include:Resident # 634 was admitted to the facility on [DATE] with diagnoses that included dementia, respiratory failure with hypoxia, atrial fibrillation, long term use of anticoagulants, anxiety, hypertensive heart disease with heart failure, and muscle weakness. The admission Minimum Data Set (MDS) dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMS) of 08, indicating moderately impaired cognition. The clinical record banner alert, retrieved July 2, 2025, with special instructions that the son…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interview, review of policies and procedures, the facility failed to notify the ombudsman of transfer or discharge. The deficit practice would result in residents not being able to inform the ombudsman being unaware for any transfer or discharge. Resident # 70 was admitted to the facility on [DATE] with diagnoses that include adult failure to thrive, HTN, BPH, Anemia. Resident # 70 was discharged [DATE]. Resident # 70 needs supervision or touching assistance with: eating, oral hygiene, and personal hygiene. Resident # 70 needs substantial/maximal assistance with: upper body dressing, lower body dressing, putting on/taking on foot wear, roll left and right, sit to lying, chair/bed-to-chair transfer. The care plan revealed Resident #70 was monitored for any change of conditions. If any change were to occur it would be reported to their provider. Resident # 70 is at risk for altered fluid balance r/t Poor intake, feeding tube. Resident # 70 has oral thrush and antifungal. Progress…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on the reviewing of staff list, census, record review and interview facility failed to ensure that a Registered Nurse (RN) severed 8 consecutive hours in the day.The deficit practice would result resident care not being property given in need of a registered nurse. Reviews of daily staff revealed that an RN was not present during the 8 hours in the day for 8 different dates. On May 19, 2024 the Census was 58 no RN coverage for day and night. On July 01, 2024 Census was 68 no RN coverage for the day for 8 hours. At the August 05, 2024 census there was 68 no RN coverage for the day for 8 hours. On August 06,2024 census was 66 for the day for 8 hours, August 12, 2024 the census was 69 and no RN coverage for 8 hours of the day. August 19,2024 census 67 no RN coverage for the day for 8 hours. August 27, 2024 census 64 no RN coverage for the day for 8 hours. September 01, 2024 census 59 no RN coverage for 8 of the day. Upon further review of the daily staffing list provided to the surveyor, Director of Nursing or Assistant of Director of Nursing are not listed on the daily staffing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and the facility policy and procedures, the facility failed to ensure pain medications were administered in accordance with the physician's orders for one resident (#15). The deficient practice could result in the resident receiving unnecessary medication and being overmedicated. Findings include: Resident #15 was admitted to the facility on [DATE] with diagnoses of a fracture of shaft of right fibula, fracture of shaft of right tibia, and acquired absence of left hip joint. A review of the quarterly Minimum Data Set (MDS) assessment, dated June 20, 2024 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact. A physician's order dated May 9, 2024 indicated Oxycodone HCI (narcotic analgesic) Oral Tablet 5 milligrams (mg) was to be given by mouth every 4 hours as needed for pain between 6-10 on a 0-10 pain scale. A review of the July and August medication administration record (MAR)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interview, and facility documentation, policy and procedure, the facility failed to ensure dialysis assessments were completed and transportation to dialysis appointments was arranged for one of three sampled residents (#4). The deficient practice could result in the resident missing dialysis treatment and developing renal complications. Findings include: The facility's contract with the Dialysis Facility, signed and dated 10/18/2023, it included that the facility shall be responsible for arranging transportation of residents to and from Dialysis Facility, including all transportation costs and expenses. Long term care facility shall be responsible for ensuring that residents are (i) medically stable to undergo such transportation, (ii) medically suitable to receive treatment at Dialysis Facility, and (iii) timely transported to and from Dialysis Facility. Resident (#4) was admitted [DATE] with diagnoses of type 2 diabetes mellitus with diabetic chronic kidney…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation, the State database, staff interviews, and policies review, the facility failed to ensure that an allegation of abuse for one resident (#45) was reported to the State within the required time frame. The deficient practice could result in further incidents of abuse not being reported as required. Findings include: Resident #45 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease and pneumonia. According to the Minimum Data Set assessment, he scored 13 on his Brief Interview for Mental Status (BIMS) which indicated cognitive intactness. He had orders for 300 milligrams (mg) of Gabapentin one time a day for neuropathy dated 10/17/23. His hospital discharge paperwork reflected this same order for 300mg of Gabapentin once a day. He had a new order for Gabapentin dated 11/9/23 for 800 mg three time a day for neuropathy. In a review of the grievance log for November 2023, the facility received a Comment and Concern Form from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY -Resident #264 was admitted to the facility on [DATE] with diagnoses that included acute pyelonephritis, urinary tract infection, chronic kidney disease, paraplegia, depression, and hypertension. Active physician orders for medications included Gabapentin, cefdinir (antibiotic), Pantoprazole (antacid), Cymbalta (antidepressant), fluconazole (antifungal), midodrine anti-hypotension), oxycodone (narcotic), Seroquel (antipsychotic), and Lovenox (anticoagulant). During an interview conducted with resident #264 on 11/07/22 at 11:20 AM, a cup full of medications was observed on the table. Resident #264 said staff knew her really well and knew that she was going to take the pills so they were okay to leave them with her. She picked up the cup and self-administered a pill. Immediately following the observation, an interview was conducted with an LPN (staff #107) who was standing outside the room. She stated that pills cannot be left with a resident and should never be taken outside of the nurse ' s view. The LPN stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, staff interviews, and review of facility policy, the facility failed to ensure one resident (#225) and/or their representatives were informed in advance of the risks and benefits of proposed treatment with psychotropic medications. The sample size was 7. The deficient practice could result in residents receiving high risk medications without education, their knowledge, or consent. Findings include: Resident #225 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The baseline care plan dated October 26, 2022 revealed the resident was admitted with impaired cognitive function or impaired thought processes related to confusion, BIMS (Brief Interview of Mental Status) score of 00 and cognitive communication deficit. The baseline care plan included that the resident used antipsychotic medication. Interventions stated to administer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy and procedures, the facility failed to notify the ombudsman in writing regarding one resident's (56) discharge. The sample size was 2. The deficient practice could result in the ombudsman not being notified of resident discharges. Findings include: Resident #56 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, hypertension, and thrombotic microangiopathy. The admission Minimum Data Set (MDS) assessment dated [DATE] included a brief interview for mental status (BIMS) score of 13 indicating the resident was cognitively intact. Review of a progress note dated August 26, 2022 revealed the resident received medications, treatments, discharge instructions, and/or written prescriptions. Review of the discharge MDS assessment dated [DATE] stated that the resident was discharged to the community on August 26, 2022. An interview was conducted on November 10, 2022 at 11:29 a.m. with the Social Services Coordinator (staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy and procedure, the facility failed to ensure medications were administered according to physician ordered parameters for one resident (#223). The sample size was 5. The deficient practice could result in residents receiving medications that may not be necessary. Findings include: Resident #223 was admitted to the facility on [DATE] with diagnoses that included hypotension, essential (primary) hypertension, paroxysmal atrial fibrillation and heart failure. Review of the clinical record revealed an order for Midodrine HCL 5 mg (milligrams) 1 tablet via PEG-tube (percutaneous endoscopic gastrostomy feeding tube) three times a day for hypertension. HOLD if SBP (systolic blood pressure) > 120, HR (Heart Rate) > 60 dated October 21, 2022. Review of the care plan initiated on November 2, 2022 revealed the resident had hypertension. The interventions stated to give hypertensive medications as ordered, and to monitor for side effects such as orthostatic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interviews, the facility failed to ensure food items in the kitchen dry storage were sealed, dated or not expired. The deficient practice could result in a potential for food borne illness. Findings include: An initial observation of the kitchen refrigerator was conducted with the Dietary Manager (staff #139) on 11/09/22 at 12:40 PM. A bottle of pickles, a bag containing nuts and potato chips were observed unlabeled and undated. In addition, a container of dried milk and peanut butter was found to be expired (10/22/22 and 10/21/22). An interview was conducted with the culinary services director (staff #139) on 11/09/22 at 12:40 PM. Staff #139 stated that it is his expectation that the food in the freezer, refrigerator and dry goods be labeled, marked and dated. He stated that he does check the dry goods area but did not look well enough to notice the items. He stated they were overlooked. An interview was conducted with the Director of Nursing (DON/staff #171) on 11/09/22 at 1:51 PM. The DON stated that it is her expectation that food in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.