A list of the most recent deficiencies for Mescalero 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? |
|---|---|---|---|---|
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-06-15 | 2023-08-31 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-06-15 | 2023-08-31 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-06-15 | 2023-08-31 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-15 | 2023-08-31 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-06-15 | 2023-08-31 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-06-15 | 2023-08-31 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-06-15 | 2023-08-31 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-06-15 | 2023-08-31 | 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 | 2023-06-15 | 2023-08-31 | 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 | 2023-06-15 | 2023-08-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-15 | 2023-08-31 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-15 | 2023-08-31 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-06-15 | 2023-08-31 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-06-15 | 2023-08-31 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-06-14 | 2023-08-31 | 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 | 2023-06-14 | 2023-08-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-06-14 | 2023-08-31 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2023-06-14 | 2023-08-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-06-14 | 2023-08-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-14 | 2023-08-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-06-14 | 2023-08-31 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-06-14 | 2023-08-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-06-14 | 2023-08-31 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-06-14 | 2023-08-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-06-14 | 2023-08-31 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-04-04 | 2022-09-07 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-04-04 | 2022-09-07 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-04-04 | 2022-09-07 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-04-04 | 2022-09-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-04 | 2022-09-07 | 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 | 2022-04-04 | 2022-09-07 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-04-04 | 2022-09-07 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-04-04 | 2022-09-07 | 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 | 2022-04-04 | 2022-09-07 | 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 | 2022-04-04 | 2022-09-07 | N |
| Provide or obtain dental services for each resident. | Health | 2022-04-04 | 2022-09-07 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-04-04 | 2022-09-07 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-04-04 | 2022-09-07 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-04-04 | 2022-09-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-04 | 2022-09-07 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-04-04 | 2022-09-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-04 | 2022-09-07 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-04-04 | 2022-09-07 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-04 | 2022-09-07 | 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 | 2022-03-30 | 2022-06-01 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-03-30 | 2022-06-01 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-03-30 | 2022-06-01 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-03-30 | 2022-05-27 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-03-30 | 2022-05-27 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-03-30 | 2022-05-27 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-03-30 | 2022-05-20 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-03-30 | 2022-05-20 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2022-03-30 | 2022-05-20 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-03-30 | 2022-05-20 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2022-03-30 | 2022-05-20 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2022-03-30 | 2022-05-06 | N |
| Establish methods for sharing information. | Fire Safety | 2022-03-30 | 2022-05-05 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2022-03-30 | 2022-05-05 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-03-30 | 2022-05-04 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2022-03-30 | 2022-05-04 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2022-03-30 | 2022-04-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-03-30 | 2022-04-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-11-24 | 2021-12-24 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-04-16 | 2021-09-27 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-04-16 | 2021-09-24 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-04-16 | 2021-09-21 | 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 | 2021-04-16 | 2021-09-21 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-04-14 | 2021-08-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-16 | 2021-08-24 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-04-16 | 2021-08-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-16 | 2021-08-10 | 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 | 2021-04-16 | 2021-08-10 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-04-16 | 2021-08-04 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-04-14 | 2021-08-03 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-04-14 | 2021-08-03 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-04-14 | 2021-08-03 | N |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2021-04-16 | 2021-07-30 | 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 | 2021-04-16 | 2021-07-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-04-14 | 2021-07-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-04-14 | 2021-07-14 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-04-16 | 2021-06-30 | N |
