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 |