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Deficiency Records for Mira Vista Care Center
A list of the most recent deficiencies for Mira Vista Care 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 Mira Vista 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 voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-07-11 | 2024-08-30 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-07-11 | 2024-08-30 | Y |
| 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 | 2024-07-11 | 2024-08-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-07-11 | 2024-08-30 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-07-25 | 2024-08-30 | 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 | 2024-07-25 | 2024-08-30 | 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 | 2024-07-25 | 2024-08-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-07-25 | 2024-08-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-07-25 | 2024-08-30 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2024-07-25 | 2024-08-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-07-25 | 2024-08-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-25 | 2024-08-30 | Y |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2024-07-18 | 2024-08-22 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-07-18 | 2024-08-22 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2024-07-18 | 2024-08-22 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2024-07-18 | 2024-08-22 | N |
| Develop a communication plan. | Fire Safety | 2024-07-18 | 2024-08-22 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2024-07-18 | 2024-08-22 | N |
| Provide emergency officials' contact information. | Fire Safety | 2024-07-18 | 2024-08-22 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2024-07-18 | 2024-08-22 | N |
| Establish emergency prep training and testing. | Fire Safety | 2024-07-18 | 2024-08-22 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-07-18 | 2024-08-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-07-18 | 2024-08-22 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-07-18 | 2024-08-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-07-18 | 2024-08-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-07-18 | 2024-08-22 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-07-18 | 2024-08-22 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-07-18 | 2024-08-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-07-18 | 2024-08-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-07-18 | 2024-08-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-07-18 | 2024-08-22 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-07-18 | 2024-08-22 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-02-14 | 2024-03-19 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-08-24 | 2023-09-11 | 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 | 2023-07-21 | 2023-08-29 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-07-21 | 2023-08-29 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-07-21 | 2023-08-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-21 | 2023-08-29 | 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 | 2023-07-21 | 2023-08-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-21 | 2023-08-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-21 | 2023-08-29 | 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 | 2023-07-21 | 2023-08-29 | N |
| Provide or obtain dental services for each resident. | Health | 2023-07-21 | 2023-08-29 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-07-21 | 2023-08-29 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-07-21 | 2023-08-29 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-07-21 | 2023-08-29 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-07-21 | 2023-08-29 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Develop a communication plan. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Meet other general requirements. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-07-17 | 2023-08-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-07-17 | 2023-08-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-12 | 2023-04-26 | 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 | 2023-01-13 | 2023-02-10 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-01-13 | 2023-02-10 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-13 | 2023-02-10 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-10-18 | 2022-11-16 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-10-18 | 2022-11-16 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-18 | 2022-11-16 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-10-18 | 2022-11-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-10-18 | 2022-11-16 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-24 | 2022-09-02 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-08 | 2021-11-30 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-01-24 | 2020-03-17 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2020-01-24 | 2020-03-17 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2020-01-24 | 2020-03-17 | 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 | 2020-01-24 | 2020-03-17 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2020-01-24 | 2020-03-17 | 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 | 2020-01-24 | 2020-03-17 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-01-24 | 2020-03-17 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2020-01-24 | 2020-03-17 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-01-24 | 2020-03-17 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-01-24 | 2020-03-17 | 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 | 2020-01-24 | 2020-03-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-01-24 | 2020-03-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-01-24 | 2020-03-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-01-24 | 2020-03-17 | N |
| Provide activities to meet all resident's needs. | Health | 2020-01-24 | 2020-03-17 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2020-01-24 | 2020-03-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-01-24 | 2020-03-17 | 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 | 2020-01-24 | 2020-03-17 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-01-24 | 2020-03-17 | N |
| Post nurse staffing information every day. | Health | 2020-01-24 | 2020-03-17 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2020-01-24 | 2020-03-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-01-24 | 2020-03-17 | 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 | 2020-01-24 | 2020-03-17 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-01-24 | 2020-03-17 | 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 | 2020-01-24 | 2020-03-17 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-01-24 | 2020-03-17 | N |
| Ensure that residents are free from significant medication errors. | Health | 2020-01-24 | 2020-03-17 | N |
| Provide or obtain dental services for each resident. | Health | 2020-01-24 | 2020-03-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-24 | 2020-03-17 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2020-01-24 | 2020-03-17 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2020-01-08 | 2020-02-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-01-08 | 2020-02-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-01-08 | 2020-02-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-08 | 2020-02-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-01-08 | 2020-02-10 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-01-08 | 2020-02-10 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2020-01-08 | 2020-02-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-01-08 | 2020-02-10 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2020-01-08 | 2020-02-10 | N |
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