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 Sante Of Mesa during CMS and state inspections, most recent first.
A resident with multiple comorbidities, including CHF, CKD, HTN, orthostatic hypotension, and chronic pain, had care plans directing staff to administer antihypertensives and analgesics as ordered. Review of the MAR for one month showed Hydrocodone‑Acetaminophen PRN for pain 6–10/10 was given for lower pain scores, and Midodrine, Sacubitril‑Valsartan, and Metoprolol Tartrate were administered despite vital signs falling outside ordered SBP and HR hold parameters. Progress notes contained no explanations for these out‑of‑parameter administrations and no evidence that a provider was notified. In interviews, an LPN and the DON confirmed multiple such occurrences and acknowledged that medications were not given in accordance with provider orders or documented as required by facility policy.
A resident with dementia and a history of risk from outside parties was not properly protected due to the facility's failure to implement and document a required password protocol for visitation. Despite a trespass order against a family member and a clinical alert, the care plan lacked a safety plan, and staff interviews confirmed the absence of documentation and awareness of the protocol, resulting in a lapse in resident safety procedures.
A facility failed to notify the ombudsman of a resident's transfer to an acute rehab center, as required by policy. The resident, who required assistance with daily activities and was progressing with therapy, was transferred without proper documentation or notification. Staff interviews revealed a misunderstanding of notification requirements, and social services were unaware of the need to notify the ombudsman.
The facility failed to ensure RN coverage for 8 consecutive hours daily, as required. On multiple occasions, there was no RN coverage for the day or night, with census numbers ranging from 58 to 69 residents. The DON or ADON were not listed on the staffing schedule, although they covered shifts when RNs were unavailable. A CNA reported caring for 11-12 residents and documenting tasks if coverage was delayed. The facility's policy required licensed nurses to provide direct resident services 24 hours a day, which was not met.
A resident with fractures and an absence of the left hip joint received Oxycodone outside the prescribed pain parameters sixty-five times over two months. Despite being cognitively intact, the resident's medication was administered without adhering to the physician's order, which specified use only for pain rated 6-10. Staff interviews confirmed the deviation from orders, and facility policies emphasized the importance of following physician directives.
A facility failed to ensure proper dialysis assessments and transportation arrangements for a resident requiring thrice-weekly dialysis. Despite physician orders and a contract with a Dialysis Facility outlining responsibilities, the resident missed a dialysis session, leading to an ER visit. Staff interviews revealed discrepancies in completing dialysis assessments and arranging transportation. The LPN and DON acknowledged missing assessments, while the unit clerk described scheduling issues. The Assistant DON noted that a fall disrupted the scheduled dialysis appointment, highlighting gaps in communication and execution of transportation and assessment procedures.
Medications Administered Outside Provider-Ordered Parameters Without Documentation or Provider Notification
Penalty
Summary
The deficiency involves the facility’s failure to administer medications according to provider-ordered parameters for one sampled resident, resulting in services that did not meet professional standards of quality. The resident was admitted with multiple diagnoses including a displaced trimalleolar fracture of the right lower leg, contusion of the lower back and pelvis, anxiety disorder, type 2 diabetes with chronic kidney disease, morbid obesity, major depressive disorder, hypertension, heart failure, orthostatic hypotension, renal insufficiency, and almost constant pain. Care plans initiated in July 2025 addressed hypertension related to CHF and kidney disease, potential for altered comfort/pain related to recent hospitalization, and a right distal fibula fracture, with interventions directing staff to administer antihypertensives and analgesics as ordered. An Admission/Medicare 5‑day MDS showed intact cognition (BIMS 13) and no rejection of care behaviors. For Hydrocodone‑Acetaminophen 5/325 mg ordered PRN every 4 hours for pain rated 6–10/10, the August 2025 MAR showed the medication was administered for pain scores below the ordered threshold, including pain levels of 2, 3, 4, and 5 on multiple dates. For Midodrine 5 mg, 0.5 tablet three times daily with instructions to hold if SBP > 140, the August MAR documented administration when SBP readings exceeded 140 on several occasions. For Sacubitril‑Valsartan 24‑26 mg ordered twice daily with instructions to hold for SBP 110 or HR < 60, the August MAR showed doses given when HR was below 60 on multiple dates. For Metoprolol Tartrate 12.5 mg twice daily ordered to be held for SBP < 110 or HR < 60, the August MAR documented administration when HR was below 60 on several occasions. Progress notes from August 1 through August 31, 2025 contained no documentation explaining why any of these medications were administered outside the ordered parameters or that the provider had been notified. In interviews, an LPN stated that facility policy is to follow provider orders as written, including parameters for blood pressure and pain medications, and that if medications are given outside parameters the provider should be notified and documentation completed. The LPN and the DON both reviewed the clinical record and confirmed multiple instances where Hydrocodone‑Acetaminophen, Midodrine, Sacubitril‑Valsartan, and Metoprolol Tartrate were administered outside provider‑ordered parameters without corresponding documentation or evidence of provider notification. The DON stated that these medications were not administered as ordered, that this did not meet her expectations, and that the clinical record lacked evidence of any provider communication regarding these deviations.
Failure to Implement and Document Password Protocol for Resident Safety
Penalty
Summary
The facility failed to implement and document a password protocol intended to protect a resident with moderately impaired cognition and a history of being at risk from outside parties. The resident, who had diagnoses including dementia, respiratory failure, atrial fibrillation, and anxiety, had a banner alert in the clinical record indicating that the resident's son was trespassed and that no information was to be shared. Despite this, the care plan did not include a safety plan, and the clinical record did not document the password protocol. A progress note indicated that a password protocol was implemented after an incident where parties entered the resident's room and created a disturbance, but these parties were unaware of the password requirement. Interviews with staff, including a CNA, LPN, the Director of Social Services, and the Executive Director, revealed that the password protocol was not documented in the resident's chart and that staff could not identify what the protocol was. The facility's policies required protection from abuse and the implementation of resident-specific safety interventions, but these were not followed in this case. The lack of documentation and communication regarding the password protocol resulted in a failure to ensure the resident's safety as required by facility policy.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to notify the ombudsman of a resident's transfer or discharge, which is a requirement according to their policy. The resident in question was admitted with diagnoses including adult failure to thrive, hypertension, benign prostatic hyperplasia, and anemia, and required various levels of assistance with daily activities. The resident was progressing with therapy and was discharged to an acute rehab center. However, there was no documentation in the progress notes regarding the date or time of discharge, nor was there evidence that the ombudsman was notified. Interviews with staff revealed a misunderstanding of the notification requirements. One LPN stated that the ombudsman would only be notified if there was a problem, and since this was a transfer between skilled nursing facilities, they did not consider it a discharge requiring notification. The administrator explained that the resident's wife had requested the transfer, and a referral was sent and approved. Despite this, there was no discharge packet provided, and social services staff were unaware of the need to notify the ombudsman, indicating a lapse in following the facility's policy on transfers and discharges.
Failure to Ensure RN Coverage for 8 Consecutive Hours Daily
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for 8 consecutive hours each day, as required. This deficiency was identified through a review of staff lists, census records, and interviews. On multiple occasions, including specific dates in May, July, August, and September 2024, the facility did not have RN coverage for the required 8 hours during the day. The census on these dates ranged from 58 to 69 residents, yet there was no RN coverage for the day or night on some occasions. Additionally, the Director of Nursing (DON) or Assistant Director of Nursing (ADON) were not listed on the daily staffing list, which further contributed to the deficiency. Interviews with staff revealed that when an RN was not available, the DON or ADON would cover the shifts, although they were not always listed on the staffing schedule. A Certified Nurse Assistant (CNA) mentioned that they typically cared for 11-12 residents and would document and report tasks and care provided if their coverage was not on time. The DON confirmed that coverage was not based on census numbers and that they did what they could with the available staff. The facility's policy required licensed nurses to provide direct resident services 24 hours a day, which was not adhered to, leading to the deficiency.
Failure to Administer Pain Medication According to Physician's Orders
Penalty
Summary
The facility failed to administer pain medications in accordance with the physician's orders for a resident who was admitted with fractures and an acquired absence of the left hip joint. The resident, who was cognitively intact, had a physician's order for Oxycodone to be administered only when their pain was rated between 6-10 on a 0-10 pain scale. However, a review of the medication administration records for July and August revealed that Oxycodone was administered below the required pain rating of 6-10 a total of sixty-five times over the two months. There was no documentation explaining why the medication was given outside the prescribed parameters, nor was the physician notified of these deviations. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, confirmed that the pain medication was not administered according to the physician's orders. The staff acknowledged that administering Oxycodone outside the specified parameters could result in the resident not receiving the appropriate treatment for their pain and could increase the risk of overmedication. The facility's policy on administering medications and pain assessment and management emphasized the importance of following physician orders and indicated that addiction to narcotic analgesics is unlikely if used appropriately for moderate to severe pain.
Deficiency in Dialysis Care Coordination and Transportation
Penalty
Summary
The facility failed to ensure proper dialysis assessments were completed and transportation to dialysis appointments was arranged for Resident #4, who required dialysis three times a week. Despite physician orders for dialysis and assessments, the resident did not receive dialysis on April 10, 2024, leading to a visit to the emergency room. The facility's contract with the Dialysis Facility outlined responsibilities for arranging transportation, ensuring medical suitability, and timely transport to and from dialysis appointments. However, documentation revealed lapses in coordinating transportation for Resident #4, resulting in missed dialysis sessions and potential health complications. Staff interviews with the LPN, Director of Nursing, and unit clerk indicated discrepancies in completing dialysis assessments and arranging transportation for Resident #4. The LPN and DON acknowledged the absence of dialysis assessments in the resident's clinical record, while the unit clerk detailed the process of scheduling transportation and responding to missed appointments. Despite the facility's policy on transportation assistance and dialysis assessment procedures, there were clear gaps in communication and execution, leading to the deficiency in providing necessary dialysis care for Resident #4. The Assistant Director of Nursing mentioned that transportation had been arranged for Resident #4 on April 10, 2024, but a fall resulting in a visit to the ER disrupted the scheduled dialysis appointment. The facility's expectation for staff to ensure residents' transportation to dialysis appointments and conduct pre- and post-dialysis assessments was not consistently met in this case. The lack of coordination and follow-up regarding transportation arrangements for dialysis appointments for Resident #4 highlights a critical deficiency in the facility's provision of essential care services for residents requiring dialysis.
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What surveyors actually found near you
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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) |
|---|---|---|---|---|
| Citadel Post Acute | 2 mi | ★★★★★ | 0 | 0 |
| Mi Casa Nursing Center | 2.5 mi | ★★★★★ | 4 | 0 |
| Desert Blossom Health & Rehab Center | 2.5 mi | ★★★★★ | 1 | 0 |
| Montecito Post Acute Care And Rehabilitation | 2.5 mi | ★★★★★ | 1 | 0 |
| Advanced Healthcare Of Mesa | 2.6 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.