Deficiency Records for Veterans Community Living Center at Fitzsimons
Updated as of March 01, 2024
A list of the most recent deficiencies for Veterans Community Living Center at Fitzsimons. 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? |
|---|---|---|---|---|
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-28 | 2023-10-20 | 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 | 2023-07-28 | 2023-08-31 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-07-28 | 2023-08-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-28 | 2023-08-31 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2023-07-28 | 2023-08-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-28 | 2023-08-31 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-07-28 | 2023-08-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-28 | 2023-08-31 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-07-28 | 2023-08-31 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-07-28 | 2023-08-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-07-28 | 2023-08-31 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-07-28 | 2023-08-31 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-07-28 | 2023-08-31 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-07-28 | 2023-08-31 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-07-28 | 2023-08-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-28 | 2023-08-31 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-07-27 | 2023-08-30 | Y |
| 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 | 2023-06-28 | 2023-08-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-28 | 2023-08-01 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-06-28 | 2023-08-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-06-28 | 2023-08-01 | 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 | 2023-06-28 | 2023-08-01 | N |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2023-06-28 | 2023-08-01 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-06-28 | 2023-08-01 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-01-20 | 2020-03-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-02-13 | 2020-03-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-13 | 2020-03-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-02-13 | 2020-03-03 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-01-20 | 2020-02-28 | N |
| Provide activities to meet all resident's needs. | Health | 2020-01-20 | 2020-02-28 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2019-02-20 | 2019-04-05 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-01-24 | 2019-04-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-01-24 | 2019-04-04 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-01-24 | 2019-04-03 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-01-24 | 2019-03-29 | N |
| Respond appropriately to all alleged violations. | Health | 2019-01-24 | 2019-03-29 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-01-24 | 2019-03-29 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-01-24 | 2019-03-29 | 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 | 2019-01-24 | 2019-03-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-01-24 | 2019-03-29 | 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 | 2019-01-24 | 2019-03-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-01-24 | 2019-03-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-02-20 | 2019-03-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-02-20 | 2019-03-06 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-02-20 | 2019-03-05 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-02-20 | 2019-03-04 | N |
