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Deficiency Records for Spanish Peaks Veterans Community Living Center
A list of the most recent deficiencies for Spanish Peaks Veterans Community Living Center. 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 Spanish Peaks Veterans Community Living 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? |
|---|---|---|---|---|
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-06-29 | 2023-08-18 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-06-29 | 2023-08-18 | 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 | 2023-06-29 | 2023-08-18 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2023-06-29 | 2023-08-18 | 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 | 2023-06-29 | 2023-08-18 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-29 | 2023-08-18 | Y |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2023-07-20 | 2023-08-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-20 | 2023-08-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-29 | 2023-08-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-07-20 | 2023-08-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-20 | 2023-07-31 | N |
| Provide activities to meet all resident's needs. | Health | 2023-06-29 | 2023-07-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-29 | 2023-07-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-29 | 2023-07-11 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-06-29 | 2023-07-06 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-06-29 | 2023-06-29 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-08-06 | 2019-09-27 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-08-06 | 2019-09-27 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-08-06 | 2019-09-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-06 | 2019-09-27 | 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 | 2019-08-06 | 2019-09-27 | 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 | 2019-08-06 | 2019-09-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-06 | 2019-09-27 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-08-06 | 2019-09-27 | 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 | 2019-09-03 | 2019-09-20 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-09-03 | 2019-09-06 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-09-03 | 2019-09-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-09-03 | 2019-09-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-03 | 2019-09-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-09-03 | 2019-09-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-08-09 | 2018-10-16 | 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 | 2018-08-09 | 2018-10-08 | 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 | 2018-08-09 | 2018-10-07 | N |
| Provide activities to meet all resident's needs. | Health | 2018-08-09 | 2018-10-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-08-09 | 2018-10-07 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2018-08-09 | 2018-10-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-08-09 | 2018-10-07 | 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 | 2018-08-09 | 2018-10-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-08-09 | 2018-10-07 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-08-09 | 2018-10-07 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2018-08-09 | 2018-10-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-09-05 | 2018-10-07 | N |
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