A list of the most recent deficiencies for Aviva 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-11 | 2023-10-12 | Y |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-08-24 | 2023-09-11 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-08-24 | 2023-09-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-24 | 2023-09-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-31 | 2023-08-03 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-07-31 | 2023-08-03 | 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 | 2023-07-31 | 2023-08-03 | 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 | 2023-07-31 | 2023-08-03 | Y |
| Provide activities to meet all resident's needs. | Health | 2023-07-31 | 2023-08-03 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-07-31 | 2023-08-03 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-07-31 | 2023-08-03 | Y |
| Keep all essential equipment working safely. | Health | 2023-07-31 | 2023-08-03 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-07-31 | 2023-08-03 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-04-06 | 2023-04-07 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-06 | 2023-04-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-06 | 2023-04-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-04-06 | 2023-04-07 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-01-02 | 2020-02-13 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2020-01-02 | 2020-02-13 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2020-01-02 | 2020-02-13 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2020-01-02 | 2020-02-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-01-02 | 2020-02-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-01-02 | 2020-02-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-01-02 | 2020-02-13 | N |
| Ensure proper storage of liquid oxygen. | Fire Safety | 2020-01-02 | 2020-02-13 | 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 | 2019-12-10 | 2020-01-09 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2019-12-10 | 2020-01-07 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-12-10 | 2020-01-02 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-12-10 | 2019-12-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-10 | 2019-12-30 | N |
