A list of the most recent deficiencies for Aspire On Evans. 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 a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-07-18 | 2023-08-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-18 | 2023-08-18 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-07-18 | 2023-08-18 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-05-11 | 2023-05-31 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-05-11 | 2023-05-31 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-05-01 | 2023-05-31 | Y |
| Provide activities to meet all resident's needs. | Health | 2022-10-24 | 2022-11-17 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2022-10-24 | 2022-11-17 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-10-24 | 2022-11-17 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-10-24 | 2022-11-17 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-10-24 | 2022-11-17 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2022-10-24 | 2022-11-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-03-09 | 2021-04-12 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-03-10 | 2021-04-10 | 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 | 2021-03-10 | 2021-04-10 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-03-10 | 2021-04-10 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-03-10 | 2021-04-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-03-10 | 2021-04-10 | N |
| Provide activities to meet all resident's needs. | Health | 2021-03-10 | 2021-04-10 | 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 | 2021-03-10 | 2021-04-10 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-03-10 | 2021-04-10 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-03-10 | 2021-04-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-03-10 | 2021-04-10 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-03-09 | 2021-04-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-03-09 | 2021-04-10 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-07-23 | 2019-11-01 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-07-23 | 2019-11-01 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-07-25 | 2019-08-25 | N |
| 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 | 2019-07-25 | 2019-08-25 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-07-25 | 2019-08-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-25 | 2019-08-25 | N |
| Provide activities to meet all resident's needs. | Health | 2019-07-25 | 2019-08-25 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-07-25 | 2019-08-25 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-07-25 | 2019-08-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-25 | 2019-08-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-25 | 2019-08-25 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-07-23 | 2019-08-25 | 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 | 2019-07-23 | 2019-08-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-07-23 | 2019-08-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-23 | 2019-08-25 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-07-23 | 2019-08-25 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2019-07-23 | 2019-08-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-07-23 | 2019-08-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-23 | 2019-08-25 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-07-23 | 2019-08-25 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2019-07-23 | 2019-08-25 | N |
