Mesa Springs Healthcare Center

In the surveyor’s words

From the most serious findings on record at Mesa Springs Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF656Oct 12, 2023

  Based on interviews and records reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to ensure the comprehensive care plan described the services and interventions to be used to attain and maintain the resident's practicable physical, mental, and psychosocial well-being for 1 (Resident #6) of 3 residents reviewed for care plans. The care plan for Resident #6 did not adequately address his interventions to describe how to meet his needs when transferring resulting in a fracture to right arm. This deficient practice placed residents at risk of not having care needs met, which could cause a decline in physical and psychosocial health and serious injury. […]

• No harm, potential for more than minimal, widespreadF851Mar 19, 2026

  Based on interview and record review, the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS, for 1 of 1 (FY Quarter 4 2025) reviewed for Staffing Data Report. The facility failed to submit staffing information to CMS for FY Quarter 4 2025 (October 1- December 31). […]

• No harm, potential for more than minimal, widespreadF812Nov 30, 2023

  Based on observations, interviews, and record review the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure that food was discarded after its use by date. The facility failed to ensure food temperatures were taken and recorded prior to service. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. Findings included: During an observation on 11/28/2023 between 10:20 AM and 10:45 AM in the kitchen revealed: Refrigerator #1 1. 2 bags of cabbage with a use by date of 11/24/2023 2. 3 bell peppers that had a white substance on them that appeared to be mold 3. […]

• No harm, potential for more than minimal, patternF695Mar 19, 2026

  Based on observation, interviews, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 3 (Resident #19, Resident#24 and Resident#31) of 12 residents reviewed for quality of care.The facility failed to ensure Resident #19 and #24's nasal canula was properly stored while oxygen was not in use on 03/17/2026.The facility failed to ensure Resident #31's nebulizer mask was properly stored while not in use on 03/17/2026. These failures could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health.The findings include:1. […]

• No harm, potential for more than minimal, patternF700Mar 19, 2026

  Based on observations, interviews, and record reviews, the facility failed to review the risks and benefits of bed rails with the resident or a resident representative and obtain informed consent prior to installation for 3 of 5 residents (Resident #2, Resident #3, and Resident #6) reviewed for bed rail consents. 1. The facility failed to obtain informed consent, or maintain evidence that, Resident #2 and Resident #3 or their representative had been provided with sufficient information so that they could make an informed decision prior to installing bed rails.2. The facility failed to obtain informed consent from Resident #6 when bed rails were installed on his bed. […]