Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Advanced Healthcare Of Mesa during CMS and state inspections, most recent first.
Failure to report and investigate an alleged abuse incident: A resident with multiple fractures, CKD, depression, and insomnia reported that an aide was rough during care and kissed him on the forehead, making him uncomfortable. The DON and Administrator were informed, but the allegation was not immediately reported to the SA, and the RN who heard the resident’s complaint did not report it because the CNA denied it. Facility abuse policy required immediate reporting of suspected abuse regardless of when it occurred, and the SOM requires reporting alleged abuse within 2 hours.
Failure to timely report an alleged abuse incident: A resident with moderate cognitive impairment and multiple fractures reported that an aide was rough during care and kissed his forehead in a way that made him uncomfortable. The RN who heard the complaint did not report it, and the DON and Administrator did not immediately report the allegation to the SA, despite facility policy requiring immediate reporting of suspected abuse.
Failure to Provide Written Bed-Hold Notice: A resident with sepsis, anemia, and HTN was transferred to the hospital after developing SOB, fever, low BP, and tachycardia. Although the chart noted that a bed hold policy was given for an emergent transfer and the family was notified, the facility could not produce a bed-hold document showing written notice of the specific duration of the bed-hold or any charges included, and staff gave inconsistent accounts of how bed holds were handled.
A facility failed to accurately complete a Discharge MDS for a resident, resulting in a discrepancy between the MDS and progress notes. The resident, admitted with multiple medical conditions, was discharged home with Home Health services, but the MDS incorrectly indicated a discharge to a hospital. Interviews revealed the RN/MDS Coordinator selected the wrong discharge option, contrary to facility expectations and policy.
The facility failed to provide written notification to two residents regarding the reason for their transfer to the hospital and did not send a copy to the ombudsman. The facility's practice was to verbally inform residents and families and notify the ombudsman at the end of the month without including the reason for the transfer.
The facility failed to notify two residents of the bed-hold policy upon transfer to the hospital. One resident was transferred after testing positive for Covid-19, and the other for possible sepsis. In both cases, there was no documentation of the bed-hold policy being provided, contrary to the facility's policy.
A facility failed to use appropriate hand hygiene and PPE when providing wound care for a resident with multiple pressure ulcers. An RN did not sanitize her hands after doffing soiled gloves and retrieved new gloves from her pocket beneath her gown, which could be contaminated. The DON confirmed these practices were not in line with the facility's policy.
Failure to Report and Investigate an Alleged Abuse Incident
Penalty
Summary
The facility failed to follow its abuse policy and regulatory reporting requirements after an allegation of abuse involving a resident admitted with multiple fractures of the pelvis, rib, sacrum, and vertebra, along with bacterial infections, chronic kidney disease, depression, and insomnia. During an interview, the resident stated that when he was first admitted, an aide was rough with him during care and held his cheeks and kissed his forehead, which made him uncomfortable. He said he told the aide’s boss about the incident and was then told the aide should not be in the same room with him. After the resident’s interview, the Administrator was informed of the allegation, but no facility self-report was found in the State Agency database at that time. The DON stated that she received a verbal report from the Administrator, interviewed the resident, and learned that the resident was fearful of explaining what happened and did not like his current aide. The DON did not complete an official investigation at that time because she was waiting for instructions from the Administrator. The Administrator later stated she did not report the allegation to the State Agency because she believed the incident occurred in July and the facility had not been informed then, and she also questioned whether the event was abuse. The RN who had been told about the resident’s allegation stated that the resident reported the CNA was inappropriate and kissed him on the forehead, and the RN told the CNA not to enter the resident’s room. The RN acknowledged he did not report the allegation because the CNA denied it. The facility policy required all personnel to immediately report suspected abuse to administration and stated that abuse must be reported regardless of the time lapse since the incident occurred. The State Operations Manual cited that all alleged violations involving abuse are to be reported immediately, but not later than 2 hours after the allegation is made.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving one resident was reported to the State Agency in a timely manner. Resident #20 was admitted with multiple fractures of the pelvis, one rib, sacrum, and vertebra, along with bacterial infections, chronic kidney disease, depression, and insomnia. An MDS dated [DATE] showed a BIMS score of 9, indicating moderate cognitive impairment. During an initial pool interview on September 2, 2025, Resident #20 stated that when he was first admitted, an aide was rough with him during care and held his cheeks while kissing his forehead, which made him uncomfortable. He said he told the aide's boss about the incident and that the aide was then told not to be in the same room as him. He also stated that he currently felt safe in the facility but was fearful of staff finding out that he reported the incident. The surveyor reported the allegation to the Administrator at 10:33 AM that day, and the Administrator stated she had not previously received a report about the allegation. The DON later stated that she had received a verbal report from the Administrator on September 2, 2025, interviewed the resident, and was waiting for instructions from the Administrator before completing an official investigation. The Administrator acknowledged that she had not reported the allegation to the SA when first informed and explained that she did not initially consider it abuse because the incident had occurred in July 2025 and the resident had issues with female aides of color. The RN who had been told about the resident's complaint in July stated that he instructed the CNA not to enter the resident's room but did not report the allegation because the CNA denied it. The facility policy required all personnel to immediately report suspected abuse, and Appendix PP states that alleged violations involving abuse are to be reported immediately, but not later than 2 hours after the allegation is made.
Failure to Provide Written Bed-Hold Notice
Penalty
Summary
The facility failed to provide written notice to the resident or resident representative that specified the duration of the state bed-hold policy, if any, during which the resident was permitted to return and resume residence in the nursing facility. The deficiency involved one resident out of a sample of 12 and was identified during record review, staff interviews, and review of facility documents and policy. Resident #48 was admitted with diagnoses including sepsis, anemia, and hypertension. The resident had a BIMS score of 15 and was cognitively intact. Progress notes showed the resident developed shortness of breath, fever, low blood pressure, and an elevated heart rate, and the nurse practitioner ordered IV Lasix, held oral Lasix, acetaminophen, and additional lab work. The resident and family requested transfer to the hospital, and the resident was discharged to a short-term general hospital. The progress note for the transfer documented that a bed hold policy was given for an emergent transfer and that the family/responsible party was notified, but the record did not contain a bed hold document for the resident. Staff interviews showed differing descriptions of who handled bed holds and when they were offered, and the facility could not produce the bed hold form when requested. The facility policy stated that prior to discharge, or as soon as possible thereafter if discharge is emergent, a written notice of the specific duration of the bed-hold and any charges included should be provided to the patient, family member, or legal representative.
Inaccurate MDS Completion for Resident Discharge
Penalty
Summary
The facility failed to properly complete a Discharge Minimum Data Set (MDS) assessment for a resident, leading to a discrepancy between the MDS and the progress notes. The resident was admitted with several medical conditions, including surgical wound infections and chronic obstructive pulmonary disease, and was discharged home with Home Health services. However, the MDS inaccurately indicated that the resident had been discharged to a short-term general hospital, which was not the case. Interviews with the RN/MDS Coordinator and the Director of Nursing revealed that the MDS was completed incorrectly, with the wrong discharge option selected. The RN/MDS Coordinator acknowledged the inaccuracy, stating it was not in line with facility expectations. The Director of Nursing confirmed that the resident was discharged home and emphasized the importance of following the Medicare Guide for accurate assessments. The facility's policy requires staff to certify the accuracy of the assessments they complete, which was not adhered to in this instance.
Failure to Provide Written Notification for Transfers
Penalty
Summary
The facility failed to ensure that two residents were notified in writing regarding the reason for their transfer and that a copy of this notification was sent to the ombudsman. Resident #86, who was cognitively intact, was transferred to the emergency department after testing positive for COVID-19 and experiencing shortness of breath. Although the family was verbally informed, there was no written notification provided to the resident or the ombudsman. Similarly, Resident #26, who had mild cognitive impairment, was transferred to the hospital without receiving a written statement regarding the reason for the transfer or the bed hold policy. The resident confirmed during an interview that he did not receive any written notification. Interviews with the Director of Nursing and the Administrator revealed that the facility's practice was to verbally inform residents and their families about hospital transfers and to notify the ombudsman at the end of the month without including the reason for the transfer. The facility's policy states that residents and their representatives should be notified in writing about transfers or discharges, and a copy should be sent to the ombudsman. However, the facility admitted to not following this policy and acknowledged the need to develop a process to ensure compliance.
Failure to Notify Residents of Bed-Hold Policy
Penalty
Summary
The facility failed to ensure that two residents were notified of the bed-hold policy upon transfer to the hospital. Resident #86, who was admitted with diagnoses including a periprosthetic fracture and chronic respiratory failure, was transferred to the emergency department after testing positive for Covid-19. Despite the family being notified about the hospital transfer and the facility's Covid-19 protocol, there was no documentation of a bed-hold policy being signed and dated by the resident or a family member. The Director of Nursing confirmed that the bed-hold policy is typically discussed with a family member in emergent situations, but it was unclear if this conversation was documented in a progress note. The Administrator stated that the resident would not have been given a bed-hold policy because the facility was not going to accept the resident back due to being Covid positive. Resident #26, who had diagnoses including benign prostatic hyperplasia and hypertensive heart disease, was transported to the hospital for possible sepsis. The clinical record did not reveal a bed-hold policy, and the resident confirmed that he did not receive a written statement regarding the bed-hold policy when transferred. The Director of Nursing mentioned that the bed-hold policy is given if feasible and discussed with a family member in emergent situations, but it was not clear if this was documented. The facility's policy states that written information about the bed-hold policy should be provided before a patient is transferred to a hospital or goes on therapeutic leave, which was not adhered to in these cases.
Inappropriate Hand Hygiene and PPE Use During Wound Care
Penalty
Summary
The facility failed to use appropriate hand hygiene practices and personal protective equipment (PPE) when providing wound care for a resident with multiple pressure ulcers. The resident, who was admitted with diagnoses including dementia, a fracture of the left femur, and abnormalities of gait and mobility, had a care plan addressing impaired skin integrity. On November 7, 2023, a Registered Nurse (RN) was observed performing wound care on the resident's left heel without sanitizing her hands after doffing soiled gloves and before donning new gloves. Additionally, the RN retrieved new gloves from her pocket beneath her gown, which could be contaminated, further increasing the risk of infection. The RN acknowledged these actions during an interview on November 8, 2023, and the Director of Nursing confirmed that these practices were not in line with the facility's policy on hand hygiene and PPE use. The facility's policy on Isolation Procedures and Universal Precautions emphasizes that hand washing is the single most important procedure for preventing infections and is necessary before and after the removal of gloves and barriers. The RN's failure to sanitize her hands and the inappropriate retrieval of gloves from beneath her gown were identified as deficiencies that could result in infection. The Director of Nursing stated that the hands should be sanitized because the old gloves may be contaminated and that reaching underneath the gown to get gloves from the pocket creates the potential for contamination, as the inside of the gown could be contaminated by touching the staff's clothing.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mesa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Desert Blossom Health & Rehab Center | 0.1 mi | ★★★★★ | 1 | 0 |
| Alta Mesa Health And Rehabilitation | 0.5 mi | ★★★★★ | 0 | 0 |
| Mi Casa Nursing Center | 0.7 mi | ★★★★★ | 4 | 0 |
| Citadel Post Acute | 0.8 mi | ★★★★★ | 0 | 0 |
| Montecito Post Acute Care And Rehabilitation | 1.2 mi | ★★★★★ | 1 | 0 |
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