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Deficiency Records for Veterans Community Living Center at Fitzsimons

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.

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?
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2023-07-28 2024-04-03 N
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
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

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