A list of the most recent deficiencies for Aspire of Sutherland. 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? |
|---|---|---|---|---|
| Install proper backup exit lighting. | Fire Safety | 2023-10-17 | 2023-11-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-17 | 2023-11-17 | 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 | 2023-10-12 | 2023-11-03 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-10-12 | 2023-11-03 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-10-12 | 2023-11-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-10-12 | 2023-11-03 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-10-12 | 2023-11-03 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-10-12 | 2023-11-03 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-10-12 | 2023-11-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-12 | 2023-11-03 | 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 | 2023-10-12 | 2023-11-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-12 | 2023-11-03 | 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 | 2023-10-12 | 2023-11-03 | 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 | 2023-10-12 | 2023-11-03 | 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 | 2023-10-12 | 2023-11-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-12 | 2023-11-03 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-10-12 | 2023-11-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-12 | 2023-11-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-12 | 2023-11-03 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-10-17 | 2023-10-23 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-10-12 | 2023-10-19 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-01 | 2023-08-08 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-01 | 2023-08-08 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-08-01 | 2023-08-08 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-08-01 | 2023-08-08 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-08-01 | 2023-08-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-01 | 2023-05-28 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-11-03 | 2022-12-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-03 | 2022-12-03 | Y |
| 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 | 2022-09-19 | 2022-10-14 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-06-23 | 2022-07-27 | 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 | 2022-06-23 | 2022-07-22 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-06-23 | 2022-07-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-06-23 | 2022-07-21 | 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 | 2022-06-16 | 2022-07-08 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-06-16 | 2022-07-08 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-06-16 | 2022-07-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-16 | 2022-07-08 | 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 | 2022-06-16 | 2022-07-08 | 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 | 2022-06-16 | 2022-07-08 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-06-16 | 2022-07-08 | 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 | 2022-06-16 | 2022-07-08 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-06-16 | 2022-07-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-16 | 2022-07-08 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-16 | 2022-07-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-16 | 2022-07-08 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-06-23 | 2022-07-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-23 | 2022-07-01 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-06-23 | 2022-07-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-06-23 | 2022-07-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-06-23 | 2022-07-01 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-06-23 | 2022-06-23 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-06-23 | 2022-06-23 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-06-23 | 2022-06-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-23 | 2022-06-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-06-23 | 2022-06-23 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-06-23 | 2022-06-23 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-11-26 | 2019-12-26 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-11-26 | 2019-12-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-11-26 | 2019-12-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-26 | 2019-12-24 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-11-26 | 2019-12-24 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-11-26 | 2019-12-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-11-26 | 2019-12-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-11-26 | 2019-12-20 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-11-21 | 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 | 2019-11-21 | 2019-12-13 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2019-11-21 | 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 | 2019-11-21 | 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 | 2019-11-21 | 2019-12-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-11-21 | 2019-12-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-21 | 2019-12-13 | 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 | 2019-11-21 | 2019-12-13 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-11-21 | 2019-12-13 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-11-21 | 2019-12-13 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2019-11-21 | 2019-12-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-21 | 2019-12-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-11-26 | 2019-12-11 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-11-26 | 2019-12-09 | 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 | 2019-11-26 | 2019-12-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-11-26 | 2019-12-05 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-11-26 | 2019-12-02 | N |
