A list of the most recent deficiencies for Aperion Care Tolleston Park. 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? |
|---|---|---|---|---|
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-11-06 | 2023-12-06 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-12 | 2023-11-14 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-09-12 | 2023-11-14 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-09-12 | 2023-10-30 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-09-12 | 2023-10-30 | N |
| Develop a communication plan. | Fire Safety | 2023-09-12 | 2023-10-30 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-09-12 | 2023-10-30 | 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 | 2023-09-12 | 2023-10-30 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-09-12 | 2023-10-30 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-09-12 | 2023-10-30 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-09-12 | 2023-10-30 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-09-12 | 2023-10-30 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-09-12 | 2023-10-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-12 | 2023-10-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-09-12 | 2023-10-30 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-09-12 | 2023-10-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-09-12 | 2023-10-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-25 | 2023-10-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-25 | 2023-10-20 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-08-25 | 2023-10-20 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-08-25 | 2023-10-20 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-25 | 2023-09-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-08-25 | 2023-09-22 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-08-25 | 2023-09-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-25 | 2023-09-22 | N |
| Provide activities to meet all resident's needs. | Health | 2023-08-25 | 2023-09-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-25 | 2023-09-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-25 | 2023-09-22 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-08-25 | 2023-09-22 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-08-25 | 2023-09-22 | 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 | 2023-08-25 | 2023-09-22 | 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 | 2023-08-25 | 2023-09-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-25 | 2023-09-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-08-25 | 2023-09-22 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2023-06-30 | 2023-07-28 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-06-30 | 2023-07-28 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-30 | 2023-07-28 | Y |
| 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 | 2023-06-30 | 2023-07-28 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-03-29 | 2023-04-21 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-12-13 | 2022-12-27 | 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 | 2022-12-13 | 2022-12-27 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-12-13 | 2022-12-27 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-08-29 | 2022-09-21 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-08-29 | 2022-09-21 | N |
| Develop a communication plan. | Fire Safety | 2022-08-29 | 2022-09-21 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-08-29 | 2022-09-21 | N |
| Use approved construction type or materials. | Fire Safety | 2022-08-29 | 2022-09-21 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-08-29 | 2022-09-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-29 | 2022-09-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-29 | 2022-09-21 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-08-29 | 2022-09-21 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-08-29 | 2022-09-21 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-08-29 | 2022-09-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-29 | 2022-09-21 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-08-05 | 2022-09-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-05 | 2022-09-13 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-08-05 | 2022-09-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-05 | 2022-09-04 | N |
| Provide activities to meet all resident's needs. | Health | 2022-08-05 | 2022-09-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-05 | 2022-09-04 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-08-05 | 2022-09-04 | N |
| Provide appropriate foot care. | Health | 2022-08-05 | 2022-09-04 | 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 | 2022-08-05 | 2022-09-04 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-08-05 | 2022-09-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-05 | 2022-09-04 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-08-05 | 2022-09-04 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-08-05 | 2022-09-04 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-05 | 2022-09-04 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-05 | 2022-09-04 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-08-05 | 2022-09-04 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-08-05 | 2022-09-04 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-08-05 | 2022-09-04 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-04-06 | 2022-04-22 | 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 | 2022-04-06 | 2022-04-22 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-06 | 2022-04-22 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-06 | 2022-04-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-06 | 2022-04-22 | Y |
| 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 | 2022-04-06 | 2022-04-22 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-04-06 | 2022-04-22 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-02-16 | 2022-02-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-16 | 2022-02-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-16 | 2022-02-28 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2022-02-02 | 2022-02-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-02 | 2022-02-20 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-02-02 | 2022-02-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-18 | 2021-11-10 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-20 | 2021-09-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-20 | 2021-09-10 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-07-20 | 2021-09-10 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-08-02 | 2021-08-19 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-08-02 | 2021-08-19 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-08-02 | 2021-08-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-08-02 | 2021-08-19 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-08-02 | 2021-08-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-08-02 | 2021-08-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-08-02 | 2021-08-19 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-08-02 | 2021-08-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-02 | 2021-08-19 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-08-02 | 2021-08-19 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-07-20 | 2021-08-09 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-07-20 | 2021-08-09 | 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 | 2021-07-20 | 2021-08-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-20 | 2021-08-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-20 | 2021-08-09 | 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 | 2021-07-20 | 2021-08-09 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-07-20 | 2021-08-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-07-20 | 2021-08-09 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-07-20 | 2021-08-09 | 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 | 2021-07-20 | 2021-08-09 | 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 | 2021-07-20 | 2021-08-09 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-07-20 | 2021-08-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-20 | 2021-08-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-28 | 2021-06-14 | N |
