Deficiency Records for Mescalero Care Center
Updated as of May 01, 2023
This is not the most recent data for Mescalero Care Center. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 |
| 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 | 2019-10-01 | 2019-12-05 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2019-10-01 | 2019-12-05 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-10-01 | 2019-11-15 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2019-10-01 | 2019-11-15 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2019-10-01 | 2019-11-15 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-10-01 | 2019-11-15 | 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 | 2019-10-01 | 2019-11-15 | 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 | 2019-10-01 | 2019-11-15 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-10-01 | 2019-11-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-10-01 | 2019-11-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-01 | 2019-11-15 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-10-01 | 2019-11-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-01 | 2019-11-15 | 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 | 2019-10-01 | 2019-11-15 | 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 | 2019-10-01 | 2019-11-15 | 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 | 2019-10-01 | 2019-11-15 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-10-01 | 2019-11-15 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2019-10-01 | 2019-11-15 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-10-01 | 2019-11-15 | 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 | 2019-10-01 | 2019-11-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-10-01 | 2019-11-15 | 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 | 2019-10-01 | 2019-11-15 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2019-10-01 | 2019-11-15 | N |
| Provide or obtain dental services for each resident. | Health | 2019-10-01 | 2019-11-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-01 | 2019-11-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-10-01 | 2019-11-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-01 | 2019-11-15 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-10-01 | 2019-11-15 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-10-01 | 2019-11-15 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2019-10-01 | 2019-11-15 | N |
