Mesa Vista Assisted Living Residence

A revisit survey was completed on 12/12/25 for all previous deficiencies cited on 7/22/25. The facility is in compliance with all deficiencies that were cited. Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A complaint revisit was completed on 7/22/25 for all previous deficiencies cited on 2/25/25. A deficiency was cited. Based on observations and interviews the residence failed to comply with the Colorado Clean Indoor Air Act, affecting 33 current residents. This deficiency was cited previously during a complaint survey on 2/25/25. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement.Findings include:1. ReferenceThe Colorado Clean Indoor Air Act, section 25-14-203 (7), defines "Entryway" as the outside of the front or main doorway leading into a building or facility that is not exempted from this part 2 under section 25-14-205. "Entryway" also includes the area of public or private property within a specified radius outside of the doorway. The specified radius may be determined by the local authority under section 25-14-207 (2)(a) but must be at least twenty-five feet unless section 25-14-207(2)(a)(II)(B) or (2)(a)(II)(C) applies. The specified radius is twenty-five feet if the local authority has not acted. Colorado Public Health and Environment.2. ObservationsOn 7/22/25 , an environmental tour of the residence was conducted at approximately, 8:23 a.m., the tour revealed an undesignated smoking area within five feet of the east side entryway. No resident was observed smoking at this entryway, which was within five feet of the entryway during the site visit, however, a silver can containing cigarette butts were found.3. InterviewsOn 7/22/25 at approximately 9 a.m., the resident service director stated that she knew who might be smoking in the undesignated smoking area; she explained that it was the resident that had a room directly next to the east entrance where the cigarette butts were found. On 7/22/25 at approximately 5:20 p.m., the administrator designee stated that he was unaware of the smoking taking place at the east entrance and noted that the maintenance staff member was responsible for checking the grounds. The administrator designee stated that he was unsure how often the maintenance staff member performed exterior rounds, but that he expecte..

A relicensure survey with complaint #CO40535 was completed on 7/22/25. Deficiencies were cited. Based on an interview and record review, the residence failed to investigate the irregularities found in the quarterly medication audits, which affected 33 current residents. Findings include:On 7/22/25, during the onsite visit, quarterly medication audits were requested from the administrator designee. However, the residence provided audits without investigating the irregularities found throughout the audit. Audit irregularities included gaps or holes in the medication administration records (MARs) for six residents on various days. One resident had a gap on their MAR for six days, with no documentation indicating whether the resident missed the medication, if there was a failure on the sta.. Based on observations and interviews the residence failed to comply with the Colorado Clean Indoor Air Act, affecting 33 current residents. This deficiency was cited previously during a complaint survey on 2/25/25. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement.Findings include:1. ReferenceThe Colorado Clean Indoor Air Act, section 25-14-203 (7), defines "Entryway" as the outside of the front or main doorway leading into a building or facility that is not exempted from this part 2 under section 25-14-205. "Entryway" also includes the area of public or private property within a specified radius outs.. Based on record review and interview the residence failed to have policies and procedures to ensure the continuation of necessary care to all residents for at least 72 hours immediately following any emergency including, but not limited to, a long-term power failure affecting 33 current residents. (Cross-reference T0920)Findings Include:1. Record ReviewOn 7/22/25 at 8:04 a.m., the residence emergency preparedness procedures were requested. On 7/22/25 at approximately 9:00 a.m., a document titled Emergency Procedures was provided with a publisheddate of April 2020. The emergency procedures provided did not include written policies and procedures to ensurethe continuation of nec.. Based on record review and interview, the residence failed to address in their emergency policies, availability of, oraccess to emergency power, assigned tasks and responsibilities to staff members on each shift, and have writtenagreements with other health facilities affecting 33 current residents. (Cross-reference T914)Findings Include:1. Record ReviewOn 7/22/25 at 8:04 a.m., the residence emergency preparedness procedures were requested. On 7/22/25 at approximately 9:00 a.m., a document titled Emergency Procedures was provided with a publisheddate of April 2020. The document did not include access to emergency power, assigned tasks and responsibilitiesof staff m.. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The facility was advised it must review and maintain the following processes in accordance with existing programregulations found at 10 CCR 2505-10.7.9 The assisted living residence shall ensure that each staff member and volunteer receives orientation andtraining, as follows: (B) Dementia Training Requirements (3) Initial Training: Each assisted living residence isresponsible for ensuring that all direct-care staff members are trained in dementia diseases and related disabilities.(b) The training shall be competency-based and culturally-competent and shall include a minimum of four..

A complaint revisit was completed on 7/22/25 for all previous deficiencies cited on 2/25/25. A deficiency was cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 3/17/25. Based on observations and interviews the residence failed to comply with the Colorado Clean Indoor Air Act, affecting 33 current residents. This deficiency was cited previously during a complaint survey on 2/25/25. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement.Findings include:1. ReferenceThe Colorado Clean Indoor Air Act, section 25-14-203 (7), defines "Entryway" as the outside of the front or main doorway leading into a building or facility that is not exempted from this part 2 under section 25-14-205. "Entryway" also includes the area of public or private property within a specified radius outside of the doorway. The specified radius may be determined by the local authority under section 25-14-207 (2)(a) but must be at least twenty-five feet unless section 25-14-207(2)(a)(II)(B) or (2)(a)(II)(C) applies. The specified radius is twenty-five feet if the local authority has not acted. Colorado Public Health and Environment.2. ObservationsOn 7/22/25 , an environmental tour of the residence was conducted at approximately, 8:23 a.m., the tour revealed an undesignated smoking area within five feet of the east side entryway. No resident was observed smoking at this entryway, which was within five feet of the entryway during the site visit, however, a silver can containing cigarette butts were found.3. InterviewsOn 7/22/25 at approximately 9 a.m., the resident service director stated that she knew who might be smoking in the undesignated smoking area; she explained that it was the resident that had a room directly next to the east entrance where the cigarette butts were found. On 7/22/25 at approximately 5:20 p.m., the administrator designee stated that he was unaware of the smoking taking place at the east entrance and noted that the maintenance staff member was responsible for checking the grounds. The administrator designee stated that he was unsure how often the maintenance staff member performed exterior rounds, but that he expecte..

A recertification survey with complaint #CO40538 was completed on 7/22/25. Deficiencies were cited. Based on observations and interviews the residence failed to comply with the Colorado Clean Indoor Air Act, affecting 33 current residents. This deficiency was cited previously during a complaint survey on 2/25/25. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement.Findings include:1. ReferenceThe Colorado Clean Indoor Air Act, section 25-14-203 (7), defines "Entryway" as the outside of the front or main doorway leading into a building or facility that is not exempted from this part 2 under section 25-14-205. "Entryway" also includes the area of public or private property within a specified radius outside of the doorway. The specified radius may be determined by the local authority under section 25-14-207 (2)(a) but must be at least twenty-five feet unless section 25-14-207(2)(a)(II)(B) or (2)(a)(II)(C) applies. The specified radius is twenty-five feet if the local authority has not acted. Colorado Public Health and Environment.2. ObservationsOn 7.. Based on record review and interview the facility (residence) failed to develop and follow written policies andprocedures to ensure the continuation of necessary care to all members (residents) for at least 72 hoursimmediately following any emergency including, but not limited to, a long-term power failure, affecting 33 currentresidents. Findings Include:1. Record ReviewOn 7/22/25 at 8:04 a.m., the residence emergency preparedness procedures were requested. On 7/22/25 at approximately 9:00 a.m., a document titled Emergency Procedures was provided with a publisheddate of April 2020. The emergency procedures provided did not include written policies and procedures to ensurethe continuation of necessary care to all residents for at least 72 hours immediately following any emergency. 2. InterviewOn 7/22/25 at approximately 11:30 a.m., the acting administrator stated that he searched the residence recordsand could not locate additional information for emergency preparedness procedures which included.. Based on record review and interview the facility failed to meet staffing requirements by having at least one staffto 16 members during the nighttime shift, affecting 33 members. Findings Include:1. Record ReviewOn 7/22/25 at 8:04 a.m., the staff schedule was requested. The staff schedule for June 2025 showed that only one staff member worked from 6:00 p.m. to 6:00 a.m. on thefollowing dates:6/1/25, 6/5/25, 6/6/25, 6/13/25, 6/14/25, and 6/20/25-6/21/25.The staff schedule for June 2025 showed that only one staff member worked from 10:00 p.m. to 6:00 a.m. on thefollowing dates:6/15/25 and 6/22/25.The staff schedule for July 2025 showed that only one staff member worked from 6:00 p.m. to 6:00 a.m. on thefollowing dates:7/3/25, 7/4/25, 7/14-7/16/25, 7/18/25The staff schedule for July 2025 showed that only one staff member worked from 10:00 p.m. to 6:00 a.m. on7/20/25.2. InterviewOn 7/22/25 at approximately 10:00 a.m., the administrator designee stated that he was informed by hissupervisor that t..