Mesa Vista Inn Health Center

In the surveyor’s words

From the most serious findings on record at Mesa Vista Inn Health Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Dec 20, 2024

  Based on interview and record review, the facility failed to ensure residents had the right to be free from accidents and hazards for 1 of 4 residents (Resident #1) reviewed for accidents and hazards. On 04/09/24, Resident #1, who resided in the Memory Care wing of the facility, managed to undo the lock on the window of his room, kick out the screen and climb out the window. Resident #1 then left the property and was not located until the morning of 04/10/24. The non-compliance was identified as past noncompliance. The IJ began on 04/09/24 and ended on 04/10/24. The facility had corrected the noncompliance before the investigation began on 12/15/24. This failure could place residents at risk of harm, serious injury, or death. […]

• No harm, potential for more than minimal, widespreadF711Jun 1, 2025

  Based on interview and record review the facility failed to ensure 1 of 2 physicians (Physician R) signed and dated resident physician orders for physicians reviewed for physician visits. The facility failed to have Physician R electronically sign physician orders. The Medical Records Director was instructed by Administrator O to electronically sign Physician R orders in the EMR using Physician R's username and password. This failure could place residents assigned to Physician R at risk for not receiving appropriate physician ordered care. […]

• No harm, potential for more than minimal, widespreadF812Aug 26, 2021

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. Cook A was not wearing a facial hair restraint in the kitchen. 2. There was an opened package of dry gravy mix in the dry storage room that was not properly sealed, labeled or dated. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. Findings included: 1. Observation on 08/24/2021 at 9:28 a.m. revealed cook A had facial hair approximately 1/4 in length along his jawline, and he was not wearing a facial hair restraint. […]

• No harm, potential for more than minimal, patternF584Apr 24, 2026

  Based on observations, interviews, and record reviews, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 3 of 8 residents (Resident #2, Resident #72, and Resident #89) whose rooms were observed for personal refrigerators. The facility failed to assist in maintaining personal refrigerator logs, in fridge thermometers, and/or discarding spoiled food for Residents #2, #72, and #89. These deficient practices could place residents at risk of food-bone illnesses.The findings were: 1.Record review of Resident #2's face sheet, dated 4/24/26, revealed the resident was a [AGE] year-old female, initially admitted to the facility on [DATE], readmitted on [DATE], with diagnoses including sacral spina bifida with… […]

• No harm, potential for more than minimal, patternF689Apr 24, 2026

  Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accidents and hazards as was possible for 3 of 18 residents (Resident #29, Resident #41, and Resident #52) reviewed for quality of care. 1. The facility failed to ensure Resident #41 did not have scissors stored openly on top of the nightstand. 2. The facility failed to ensure Resident #52 did not have a bottle of mouth wash in a shared room with Resident #11. 3. The facility failed to ensure Resident #29 did not have mouth wash or tiger balm in her room. These failures could place residents at risk of harm or injury and contribute to avoidable accidents and a decline in health. […]