A list of the most recent deficiencies for Mesa Verde Post Acute Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-01-24 | 2023-02-10 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-01-24 | 2023-02-10 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-22 | 2022-10-21 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-22 | 2022-10-21 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-09-22 | 2022-10-21 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-09-22 | 2022-10-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-23 | 2022-09-22 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-22 | 2022-04-15 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-04 | 2022-03-31 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-01 | 2022-03-24 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-03-01 | 2022-03-24 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-03-01 | 2022-03-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-01 | 2022-03-24 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-03-01 | 2022-03-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-01 | 2022-03-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-01 | 2022-03-24 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-03-01 | 2022-03-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-03-01 | 2022-03-24 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-03-01 | 2022-03-24 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-03-01 | 2022-03-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-01 | 2022-03-24 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-03-01 | 2022-03-24 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-03-01 | 2022-03-24 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-03-01 | 2022-03-24 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-03-01 | 2022-03-24 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2022-03-01 | 2022-03-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-01 | 2022-03-24 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-01 | 2022-03-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-01 | 2022-03-24 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-03-01 | 2022-03-24 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2022-03-01 | 2022-03-24 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2022-02-28 | 2022-03-11 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-02-28 | 2022-03-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-02-28 | 2022-03-11 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2022-02-28 | 2022-03-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-02-28 | 2022-03-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-02-28 | 2022-03-11 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-01-27 | 2022-02-15 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-09-01 | 2021-09-30 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-09-01 | 2021-09-30 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-09-01 | 2021-09-30 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-09-01 | 2021-09-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-24 | 2021-09-27 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-06-15 | 2021-07-15 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-06-15 | 2021-07-15 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-06-15 | 2021-07-15 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-06-15 | 2021-07-15 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2021-06-14 | 2021-07-14 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-12-04 | 2019-12-30 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-12-04 | 2019-12-30 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-12-04 | 2019-12-30 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-12-04 | 2019-12-30 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-12-04 | 2019-12-30 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-12-04 | 2019-12-30 | N |
| Use approved construction type or materials. | Fire Safety | 2019-12-04 | 2019-12-30 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-12-04 | 2019-12-30 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-12-04 | 2019-12-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-12-04 | 2019-12-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-04 | 2019-12-30 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-12-04 | 2019-12-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-12-04 | 2019-12-30 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-12-04 | 2019-12-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-12-04 | 2019-12-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-11-13 | 2019-12-13 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-11-13 | 2019-12-13 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-11-13 | 2019-12-13 | N |
| Maintain 15 months of resident assessments in the resident's active clinical record. | Health | 2019-11-13 | 2019-12-13 | N |
| Provide activities to meet all resident's needs. | Health | 2019-11-13 | 2019-12-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-13 | 2019-12-13 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-11-13 | 2019-12-13 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-11-13 | 2019-12-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-13 | 2019-12-13 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-11-13 | 2019-12-13 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2019-11-13 | 2019-12-13 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-11-13 | 2019-12-13 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-11-13 | 2019-12-13 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-11-13 | 2019-12-13 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-11-13 | 2019-12-13 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-11-13 | 2019-12-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-13 | 2019-12-13 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2019-11-13 | 2019-12-13 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-02-28 | 2019-03-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-02-28 | 2019-03-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-02-28 | 2019-03-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-02-28 | 2019-03-19 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-12-21 | 2019-01-21 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2018-12-21 | 2019-01-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-12-21 | 2019-01-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-12-21 | 2019-01-21 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-12-21 | 2019-01-21 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-12-21 | 2019-01-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-12-21 | 2019-01-21 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-12-21 | 2019-01-21 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2018-12-21 | 2019-01-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-12-21 | 2019-01-21 | N |
| Keep all essential equipment working safely. | Health | 2018-12-21 | 2019-01-21 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-12-21 | 2019-01-21 | N |
