A list of the most recent deficiencies for Aspire at Colonial Lakes. 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 request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-03-08 | 2023-04-07 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2023-03-08 | 2023-04-07 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-01-05 | 2023-02-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-05 | 2023-02-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-05 | 2023-02-05 | Y |
| Post nurse staffing information every day. | Health | 2022-12-01 | 2023-01-01 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-08-18 | 2022-09-19 | N |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2022-08-18 | 2022-09-19 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-08-18 | 2022-09-19 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-08-18 | 2022-09-19 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-08-18 | 2022-09-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-18 | 2022-09-19 | 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 | 2022-08-18 | 2022-09-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-18 | 2022-09-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-18 | 2022-09-19 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-08-18 | 2022-09-19 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-08-18 | 2022-09-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-18 | 2022-09-19 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-08-18 | 2022-09-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-18 | 2022-09-19 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-08-18 | 2022-09-19 | Y |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-08-17 | 2022-09-19 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-08-17 | 2022-09-19 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-08-17 | 2022-09-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-17 | 2022-09-19 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-08-17 | 2022-09-19 | 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 | 2022-01-23 | 2022-02-23 | 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 | 2021-10-06 | 2021-11-06 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-01-28 | 2021-02-28 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-01-28 | 2021-02-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-01-28 | 2021-02-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-01-28 | 2021-02-28 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-01-28 | 2021-02-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-01-28 | 2021-02-28 | N |
| Use approved construction type or materials. | Fire Safety | 2021-01-27 | 2021-02-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-01-27 | 2021-02-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-01-27 | 2021-02-28 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-01-27 | 2021-02-28 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-01-27 | 2021-02-28 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-06-20 | 2019-08-16 | 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 | 2019-06-20 | 2019-08-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-06-20 | 2019-08-16 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-06-20 | 2019-08-16 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-06-20 | 2019-08-16 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-06-20 | 2019-08-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-06-20 | 2019-08-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-20 | 2019-08-16 | N |
