Sante of Mesa

In the surveyor’s words

From the most serious findings on record at Sante of Mesa, in the surveyor’s own words.

• Actual harm, isolatedF600Oct 8, 2021

  Based on clinical record review, facility documents, staff interviews, personnel record review, the State Agency complaint database, review of Police and Medical Examiner documents, and policies and procedures, the facility failed to ensure that one resident (#318) was free from neglect, by failing to ensure the resident was not administered oral medications through an intravenous line. Resident #318 coded and expired. The deficient practice could result in residents not being provided the necessary services to prevent harm. Findings include: Resident #318 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Evaluation dated [DATE] revealed the resident arrived to the facility on [DATE] at 5:00 PM. […]

• No harm, potential for more than minimal, patternF554Nov 10, 2022

  Based on clinical record reviews, observations, staff interviews, and policy and procedure, the facility failed to ensure medications were not left unattended for 4 residents (#214, #215, #216 and #264) who were not assessed for self-administration of medications. The sample size was 16. The deficient practice could result in residents unsafely administering medications. Findings include: -Resident #214 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, chronic obstructive pulmonary disease with (acute) lower respiratory infection, heart failure, hypertension and paroxysmal atrial fibrillation. During a medication administration observation conducted on November 8, 2022 at 7:39 A.M. […]

• No harm, potential for more than minimal, patternF757Oct 8, 2021

  Based on clinical record review, staff interviews, and policy and procedures, the facility failed to ensure two residents (#46 and #54) was free from unnecessary medication. The sample size was 5. The deficient practice could result in residents receiving medications that may not be necessary. Findings include: -Resident #46 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the clinical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of October 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, isolatedF684Sep 4, 2025

  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… […]

• No harm, potential for more than minimal, isolatedF563Jul 2, 2025

  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. […]