A list of the most recent deficiencies for Aspire of Lake 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-01-31 | 2023-02-24 | 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 | 2023-01-31 | 2023-02-24 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-01-31 | 2023-02-24 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-01-31 | 2023-02-24 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-01-31 | 2023-02-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-31 | 2023-02-24 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-01-31 | 2023-02-24 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-01-31 | 2023-02-24 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-01-31 | 2023-02-24 | N |
| Post nurse staffing information every day. | Health | 2023-01-31 | 2023-02-24 | 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 | 2023-01-31 | 2023-02-24 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-01-31 | 2023-02-24 | 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 | 2023-01-31 | 2023-02-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-31 | 2023-02-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-31 | 2023-02-24 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-01-31 | 2023-02-24 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-01-31 | 2023-02-24 | 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 | 2023-01-31 | 2023-02-24 | 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 | 2023-01-31 | 2023-02-24 | Y |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-01-30 | 2023-02-09 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-01-30 | 2023-02-08 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-01-30 | 2023-02-06 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-01-30 | 2023-02-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-01-30 | 2023-02-06 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-01-30 | 2023-02-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-01-30 | 2023-02-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-01-30 | 2023-01-30 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-01-30 | 2023-01-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-31 | 2022-12-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-20 | 2022-10-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-20 | 2022-10-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-14 | 2021-11-18 | 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 | 2021-10-14 | 2021-11-18 | 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 | 2021-10-07 | 2021-11-09 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-10-07 | 2021-11-09 | N |
| Assess the resident when there is a significant change in condition | Health | 2021-10-07 | 2021-11-09 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-10-07 | 2021-11-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-07 | 2021-11-09 | 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 | 2021-10-07 | 2021-11-09 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-10-07 | 2021-11-09 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-10-07 | 2021-11-09 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-10-07 | 2021-11-09 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-10-07 | 2021-11-09 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-10-07 | 2021-11-09 | Y |
| Post nurse staffing information every day. | Health | 2021-10-07 | 2021-11-09 | Y |
| 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 | 2021-10-07 | 2021-11-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-07 | 2021-11-09 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2021-09-29 | 2021-11-09 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-09-29 | 2021-11-09 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-09-29 | 2021-11-09 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-09-29 | 2021-11-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-09-29 | 2021-11-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-29 | 2021-11-09 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-09-29 | 2021-11-09 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-09-29 | 2021-11-08 | N |
| Use approved construction type or materials. | Fire Safety | 2021-09-29 | 2021-10-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-09-29 | 2021-10-18 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-09-29 | 2021-10-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-09-29 | 2021-10-06 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2021-09-29 | 2021-10-06 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-09-29 | 2021-09-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-09-29 | 2021-09-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-12 | 2020-01-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-12-03 | 2020-01-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-12-12 | 2020-01-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-12-12 | 2019-12-30 | 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 | 2019-12-12 | 2019-12-30 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-12-12 | 2019-12-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-12 | 2019-12-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-12-03 | 2019-12-22 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-12-12 | 2019-12-16 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2019-12-12 | 2019-12-13 | 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 | 2019-12-12 | 2019-12-13 | 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 | 2019-12-12 | 2019-12-13 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-12-12 | 2019-12-13 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-12-12 | 2019-12-13 | 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 | 2019-12-12 | 2019-12-13 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-12-12 | 2019-12-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-12-12 | 2019-12-13 | 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 | 2019-12-12 | 2019-12-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-03 | 2019-12-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-12-03 | 2019-12-06 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-12-03 | 2019-12-06 | 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 | 2019-12-03 | 2019-12-05 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-12-03 | 2019-12-04 | N |
