A list of the most recent deficiencies for Mesa Glen 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 | 2023-10-08 | 2023-11-13 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-08 | 2023-11-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-08 | 2023-11-13 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-10-08 | 2023-11-13 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-30 | 2023-07-21 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-06-29 | 2023-07-21 | Y |
| 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 | 2023-06-12 | 2023-07-14 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-05-31 | 2023-06-30 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-04-06 | 2023-04-24 | Y |
| 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 | 2023-04-06 | 2023-04-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-21 | 2022-12-29 | Y |
| Keep all essential equipment working safely. | Health | 2022-12-21 | 2022-12-22 | Y |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-11-04 | 2022-12-19 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-11-15 | 2022-12-09 | 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 | 2022-10-15 | 2022-11-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-10-14 | 2022-10-26 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-06 | 2022-10-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-06 | 2022-10-14 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-08 | 2022-09-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-08 | 2022-09-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-22 | 2022-09-09 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-29 | 2022-09-07 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-06-30 | 2022-08-16 | 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 | 2022-05-17 | 2022-06-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-17 | 2022-06-14 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-05-17 | 2022-06-14 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-05-27 | 2022-06-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-27 | 2022-06-02 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-04-14 | 2022-05-20 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-04-15 | 2022-05-14 | 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 | 2021-11-05 | 2021-12-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-05 | 2021-12-12 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-09-17 | 2021-10-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-17 | 2021-10-28 | 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 | 2021-10-13 | 2021-10-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-13 | 2021-10-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-06-08 | 2021-09-29 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2021-08-26 | 2021-09-07 | Y |
| Construct fire resistant interior walls. | Fire Safety | 2021-06-18 | 2021-07-10 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-06-18 | 2021-07-10 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-06-18 | 2021-07-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-06-18 | 2021-07-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-06-18 | 2021-07-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-06-18 | 2021-07-10 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2021-06-18 | 2021-07-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-06-17 | 2021-07-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-17 | 2021-07-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-17 | 2021-07-09 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-17 | 2021-07-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-17 | 2021-07-09 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-06-17 | 2021-07-09 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-06-17 | 2021-07-09 | 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 | 2021-06-17 | 2021-07-09 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-06-17 | 2021-07-09 | 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 | 2021-06-17 | 2021-07-09 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-06-17 | 2021-07-09 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-06-17 | 2021-07-09 | 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 | 2021-06-17 | 2021-07-09 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-06-17 | 2021-07-09 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-06-17 | 2021-07-09 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-06-17 | 2021-07-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-17 | 2021-07-09 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2021-06-17 | 2021-07-09 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-06-17 | 2021-07-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-17 | 2021-07-09 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-06-17 | 2021-07-09 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-06-17 | 2021-07-09 | N |
| 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 | 2021-06-17 | 2021-07-09 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-03-20 | 2020-04-22 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-03-20 | 2020-04-22 | 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 | 2020-03-20 | 2020-04-22 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2020-03-20 | 2020-04-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-03-20 | 2020-04-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-03-20 | 2020-04-22 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-03-20 | 2020-04-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-03-20 | 2020-04-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-03-20 | 2020-04-22 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-03-20 | 2020-04-22 | 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 | 2020-03-20 | 2020-04-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-03-20 | 2020-04-22 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-03-20 | 2020-04-22 | 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 | 2020-03-20 | 2020-04-22 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2020-03-20 | 2020-04-22 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2020-03-20 | 2020-04-22 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-03-20 | 2020-04-22 | 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 | 2020-03-20 | 2020-04-22 | 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 | 2020-03-20 | 2020-04-22 | 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 | 2020-03-20 | 2020-04-22 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2020-03-20 | 2020-04-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-03-20 | 2020-04-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-03-20 | 2020-04-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-03-20 | 2020-04-22 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2020-03-20 | 2020-04-22 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2020-03-20 | 2020-04-22 | 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 | 2020-03-20 | 2020-04-22 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-03-16 | 2020-04-10 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2020-03-16 | 2020-04-10 | 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 | 2020-03-16 | 2020-04-10 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2020-03-16 | 2020-04-10 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2020-03-16 | 2020-04-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-03-16 | 2020-04-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-03-16 | 2020-04-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-03-16 | 2020-04-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-03-16 | 2020-04-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-03-05 | 2019-04-04 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-03-05 | 2019-04-04 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-03-05 | 2019-04-04 | 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 | 2019-03-05 | 2019-04-04 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-03-05 | 2019-04-04 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-03-05 | 2019-04-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-05 | 2019-04-04 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-03-05 | 2019-04-04 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2019-03-05 | 2019-04-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-03-05 | 2019-04-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-03-05 | 2019-04-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-03-05 | 2019-04-04 | 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 | 2019-03-05 | 2019-04-04 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-03-05 | 2019-04-04 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-03-05 | 2019-04-04 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-03-05 | 2019-04-04 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-03-05 | 2019-04-04 | 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 | 2019-03-05 | 2019-04-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-03-05 | 2019-04-04 | 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 | 2019-03-05 | 2019-04-04 | 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 | 2019-03-05 | 2019-04-04 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-03-05 | 2019-04-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-05 | 2019-04-04 | 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 | 2019-03-05 | 2019-04-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-05 | 2019-04-04 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-03-05 | 2019-04-04 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2019-03-08 | 2019-04-01 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-03-08 | 2019-04-01 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-03-08 | 2019-04-01 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-03-08 | 2019-04-01 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-03-08 | 2019-04-01 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2019-03-08 | 2019-04-01 | N |
| Develop a communication plan. | Fire Safety | 2019-03-08 | 2019-04-01 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-03-08 | 2019-04-01 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-03-08 | 2019-04-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-03-08 | 2019-04-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-03-08 | 2019-04-01 | N |
