A list of the most recent deficiencies for Aspire Transitional Care. 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-18 | 2023-10-03 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-18 | 2023-10-03 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-08-18 | 2023-10-03 | 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 | 2023-08-18 | 2023-10-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-18 | 2023-10-03 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-08-18 | 2023-10-03 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-08-18 | 2023-10-03 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-08-18 | 2023-10-03 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-08-18 | 2023-10-03 | N |
| 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. | Fire Safety | 2023-08-18 | 2023-10-03 | 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 | 2023-08-18 | 2023-10-03 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-18 | 2023-10-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-18 | 2023-10-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-18 | 2023-10-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-08-18 | 2023-10-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-18 | 2023-10-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-08-18 | 2023-10-03 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2023-08-18 | 2023-10-03 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-26 | 2023-08-03 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-05-26 | 2023-08-03 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-23 | 2022-08-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-06-23 | 2022-08-19 | 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 | 2022-06-23 | 2022-08-19 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-06-23 | 2022-08-19 | 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 | 2022-06-23 | 2022-08-19 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-06-23 | 2022-08-19 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-23 | 2022-08-19 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-06-23 | 2022-08-01 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-06-23 | 2022-08-01 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2022-06-23 | 2022-08-01 | N |
| 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. | Fire Safety | 2022-06-23 | 2022-08-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-06-23 | 2022-08-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-23 | 2022-08-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-06-23 | 2022-08-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-23 | 2022-08-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-06-23 | 2022-08-01 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-11-22 | 2020-01-28 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-11-22 | 2020-01-28 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-11-22 | 2020-01-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-11-22 | 2020-01-28 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2019-11-22 | 2020-01-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-11-22 | 2020-01-28 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-11-22 | 2020-01-28 | 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 | 2019-11-22 | 2020-01-23 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-11-22 | 2020-01-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-22 | 2020-01-23 | 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 | 2019-11-22 | 2020-01-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-11-22 | 2020-01-23 | N |
| Provide activities to meet all resident's needs. | Health | 2019-11-22 | 2020-01-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-22 | 2020-01-23 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-11-22 | 2020-01-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-11-22 | 2020-01-23 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-11-22 | 2020-01-23 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2019-11-22 | 2020-01-23 | N |
| Post nurse staffing information every day. | Health | 2019-11-22 | 2020-01-23 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-11-22 | 2020-01-23 | 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 | 2019-11-22 | 2020-01-23 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-11-22 | 2020-01-23 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2019-11-22 | 2020-01-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-22 | 2020-01-23 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-11-22 | 2020-01-23 | N |
