Green House Homes at Mirasol, the

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

Egress Deficiencies

Meet other general requirements that are deficient.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Miscellaneous Deficiencies

Provide a written emergency evacuation plan.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

Quality of Life and Care Deficiencies

Ensure the activities program is directed by a qualified professional.

Egress Deficiencies

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.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Nutrition and Dietary Deficiencies

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

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.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the installation and maintenance of electrical systems.

General Observations:The Fire Alarm Sensitivity testing dated 05/11/2023 did not have the acceptable values .. General Observations:The Fire Alarm Sensitivity testing dated 05/11/2023 did not have the acceptable values .. General Observations:The Fire Alarm Sensitivity testing dated 05/11/2023 recorded 8 values that were out of range p.. General Observations:The Fire Alarm Sensitivity testing dated 05/11/2023 recorded 16 values that were out of range .. General Observations:The Fire Alarm Sensitivity testing dated 05/11/2023 recorded 18 values that were out of range .. INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general charact.. INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general charact.. INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general charact.. INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general charact.. INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general charact.. INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general charact.. INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general charact.. INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general charact.. INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general charact.. Through documentation review, it was determined that the facility failed to meet the Cooking Facility requirements .. Through documentation review, it was determined that the facility failed to meet the Cooking Facility requirements .. Through documentation review, it was determined that the facility failed to meet the Electrical Systems - Maintenan.. Through documentation review, it was determined that the facility failed to meet the Evacuation and Relocation Pla.. Through documentation review, it was determined that the facility failed to meet the Evacuation and Relocation Pla.. Through documentation review, it was determined that the facility failed to meet the Fire Alarm Testing requ.. Through documentation review, it was determined that the facility failed to meet the Fire Alarm Testing requ.. Through documentation review, it was determined that the facility failed to meet the Fire Drill requirements in acco.. Through documentation review, it was determined that the facility failed to meet the Fire Drill requirements in acco.. Through documentation review, it was determined that the facility failed to meet the Fire Drill requirements in acco.. Through documentation review, it was determined that the facility failed to meet the Fire Drill requirements in acco.. Through documentation review, it was determined that the facility failed to meet the Fire Drill requirements in acco.. Through documentation review, it was determined that the facility failed to meet the Fire Drill requirements in acco.. Through documentation review, it was determined that the facility failed to meet the Fire Drill requirements in acco.. Through documentation review, it was determined that the facility failed to meet the Fire Drill requirements in acco.. Through documentation review, it was determined that the facility failed to meet the Fire Drill requirements in acco.. Through documentation review, it was determined that the facility failed to meet the Sprinkler System - Maintenanc.. Through documentation review, it was determined that the facility failed to meet the Sprinkler System - Maintenanc.. Through documentation review, it was determined that the facility failed to meet the Sprinkler System - Maintenanc.. Through observation and documentation review, it was determined that the facility failed to meet the HVAC require.. Through observation and documentation review, it was determined that the facility failed to meet the HVAC require.. Through observation and documentation review, it was determined that the facility failed to meet the HVAC require.. Through observation during the survey OR documentation review, it was determined that the facility failed to meet t.. Through observation during the survey OR documentation review, it was determined that the facility failed to meet t.. Through observation during the survey, it was determined that the facility failed to meet the Egress Door requiremen.. Through observation during the survey, it was determined that the facility failed to meet the Gas Equiptment- Transf.. Through observation during the survey, it was determined that the facility failed to meet the General Requirements .. Through observation during the survey, it was determined that the facility failed to meet the General Requirements ..

A recertification survey, with Incidents #39363, #39463, and #CO39460, was completed on 3/9/25 to 3/12/25. Five deficiencies were cited. An Emergency Preparedness survey was conducted from 3/9/25 to 3/12/25. One deficiency was cited. Based on interviews and record review, the facility failed to ensure the activities program was directed by a qualified professional. Specifically, the facility failed to employ a qualified activities director in order to provide a program of activities for residents requiring activity and recreational support. Findings include: I. Professional reference According to the National Certification Council of Activity Professionals (NCCAP) (2023),.. Based on observations, interviews and record review, the facility failed to ensure infection control practices were established and maintained to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections.Specifically, the facility failed to: -Ensure staff donned (put on) the appropriate personal protective equipment (PPE) while providing direct care for Resident #46 and Resident #.. Based on observations, record review and interviews, the facility failed to develop an antibiotic stewardship program that promotes the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance for three (#80, #46 and #2) of three residents out of 37 sample residents. Specifically, the facility failed to:-Ensure clinical signs and symptoms of an infection were identified and/or culture results were .. Based on observations, record review and interviews, the facility failed to provide needed care and services that are resident centered, in accordance with the resident' s preferences, goals for care and professional standards of practice that will meet each resident' s physical, mental, and psychosocial needs for two (#10 and #40) of two residents out of 37 sample residents. Specifically, the facility failed to:-Ensure staff provided edema care per physician' s order for Re.. Based on record review and interview, the facility failed to conduct two exercises annually (in the last 12-month cycle) to test the facility' s emergency preparedness (EP) plan and maintain documentation of the facility' s response to the two exercises and revised the facility' s emergency plan, as needed.Specifically, the facility failed to:-Documented completion of the testing activity as required; and,-Analyze and document the facility' s response to each of the two t.. Based on record review and interviews, the facility failed to ensure a response, action, and rationale to residents involved in group grievances. Specifically, the facility failed to provide a response, action, and rationale for resident concerns brought up in the resident council meetings, related to staff not making the residents' beds, the type of mattresses provided by the facility and the type of napkins provided during mealtime. Findings include: I. Facility pol..