A list of the most recent deficiencies for Access Mental Health. 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? |
|---|---|---|---|---|
| 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 | 2023-07-19 | 2023-09-27 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-07-19 | 2023-09-27 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-07-19 | 2023-09-27 | 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 | 2023-07-19 | 2023-09-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-19 | 2023-09-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-19 | 2023-09-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-07-19 | 2023-09-27 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-07-19 | 2023-09-27 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-07-19 | 2023-09-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-19 | 2023-09-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-07-19 | 2023-09-27 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-06-14 | 2023-07-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-14 | 2023-07-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-14 | 2023-07-14 | 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 | 2023-06-14 | 2023-07-14 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-14 | 2023-07-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-14 | 2023-01-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-21 | 2022-07-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-17 | 2022-06-02 | Y |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2022-02-01 | 2022-04-04 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-02-01 | 2022-04-04 | N |
| Develop a communication plan. | Fire Safety | 2022-02-01 | 2022-04-04 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-02-01 | 2022-04-04 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-02-01 | 2022-04-04 | 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 | 2022-02-01 | 2022-04-04 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-02-01 | 2022-04-04 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-02-01 | 2022-04-04 | 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 | 2022-02-01 | 2022-04-04 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-02-01 | 2022-04-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-02-01 | 2022-04-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-01 | 2022-04-04 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-02-01 | 2022-04-04 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-02-01 | 2022-04-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-02-01 | 2022-04-04 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-02-01 | 2022-04-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-02-01 | 2022-04-04 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-02-01 | 2022-04-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-02-01 | 2022-04-04 | 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 | 2022-01-14 | 2022-02-28 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-01-14 | 2022-02-28 | 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 | 2022-01-14 | 2022-02-28 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-01-14 | 2022-02-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-14 | 2022-02-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-14 | 2022-02-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-14 | 2022-02-28 | N |
| Report COVID19 data to residents and families. | Health | 2022-01-14 | 2022-02-28 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-01-14 | 2022-02-28 | N |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2022-01-14 | 2022-02-28 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-01-14 | 2022-02-28 | 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 | 2021-11-03 | 2021-12-10 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-11-03 | 2021-12-10 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2021-11-03 | 2021-12-10 | Y |
| Keep all essential equipment working safely. | Health | 2021-11-03 | 2021-12-10 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-09-13 | 2021-10-08 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2020-08-20 | 2020-09-30 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2020-08-20 | 2020-09-30 | 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 | 2020-08-20 | 2020-09-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-08-20 | 2020-09-30 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-08-20 | 2020-09-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-08-20 | 2020-09-30 | 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 | 2020-08-20 | 2020-09-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-08-20 | 2020-09-30 | 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 | 2020-08-20 | 2020-09-30 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2020-08-20 | 2020-09-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-08-20 | 2020-09-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-08-20 | 2020-09-30 | N |
| Implement a program that monitors antibiotic use. | Health | 2020-08-20 | 2020-09-30 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2020-08-20 | 2020-09-30 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-01-13 | 2020-02-15 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2020-01-13 | 2020-02-15 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2020-01-13 | 2020-02-15 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2020-01-13 | 2020-02-15 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2020-01-13 | 2020-02-15 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-01-13 | 2020-02-15 | N |
| Use approved construction type or materials. | Fire Safety | 2020-01-13 | 2020-02-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-01-13 | 2020-02-15 | 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 | 2020-01-13 | 2020-02-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-01-13 | 2020-02-15 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2020-01-13 | 2020-02-15 | 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 | 2020-01-13 | 2020-02-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-01-13 | 2020-02-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-01-13 | 2020-02-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-13 | 2020-02-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-01-13 | 2020-02-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-01-13 | 2020-02-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-01-13 | 2020-02-15 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2020-01-13 | 2020-02-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-01-13 | 2020-02-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-01-13 | 2020-02-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-01-13 | 2020-02-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-01-13 | 2020-02-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-01-13 | 2020-02-15 | N |
