Sante of Mesa

Inspectors wroteBased 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. [...]

Inspectors wroteThe 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wrote-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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.