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Deficiency Records for Access Mental Health
View the most recent health deficiencies and inspection results for Access Mental Health. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Access Mental Health. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-12-10 | 2026-02-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2025-12-10 | 2026-02-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2025-12-10 | 2026-02-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2025-12-10 | 2026-02-19 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2025-12-10 | 2026-02-17 | 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 | 2025-12-10 | 2026-02-13 | N |
| Meet other general requirements. | Fire Safety | 2025-12-10 | 2026-02-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2025-12-10 | 2026-01-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-12-10 | 2026-01-23 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2025-12-10 | 2026-01-23 | 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 | 2025-12-10 | 2026-01-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-12-10 | 2026-01-23 | 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 | 2025-12-10 | 2026-01-23 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2025-12-10 | 2025-11-05 | Y |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2025-06-23 | 2025-09-08 | N |
| Use approved construction type or materials. | Fire Safety | 2025-06-23 | 2025-09-08 | 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 | 2025-06-23 | 2025-09-08 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2025-06-23 | 2025-09-08 | 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 | 2025-06-23 | 2025-09-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2025-06-23 | 2025-09-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2025-06-23 | 2025-09-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2025-06-23 | 2025-09-08 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2025-06-23 | 2025-08-07 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2025-06-23 | 2025-07-25 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2025-06-23 | 2025-07-25 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2025-06-23 | 2025-07-25 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2025-06-23 | 2025-07-25 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2025-06-23 | 2025-07-25 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-06-23 | 2025-07-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2025-06-23 | 2025-07-25 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2025-06-23 | 2025-07-25 | Y |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2025-01-15 | 2025-03-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2025-01-15 | 2025-03-14 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2025-01-15 | 2025-03-14 | 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 | 2025-01-15 | 2025-03-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2025-01-15 | 2025-03-14 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2025-01-15 | 2025-03-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2025-01-15 | 2025-03-14 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2025-01-15 | 2025-03-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-01-15 | 2025-03-14 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2025-01-15 | 2025-03-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2025-01-15 | 2025-03-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2025-01-15 | 2025-03-14 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2025-01-15 | 2025-03-14 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2025-01-15 | 2025-03-14 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2025-01-15 | 2025-03-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2025-01-15 | 2025-03-14 | 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 | 2025-01-15 | 2025-02-12 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-01-15 | 2025-02-12 | 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 | 2025-01-15 | 2025-02-12 | 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 | 2025-01-15 | 2025-02-12 | Y |
| 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 | 2025-01-15 | 2025-02-12 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2025-01-15 | 2025-02-12 | Y |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2025-01-15 | 2025-02-12 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2025-01-15 | 2025-02-12 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2025-01-15 | 2025-02-12 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2025-01-15 | 2025-02-12 | Y |
| 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 | 2025-01-15 | 2025-02-12 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-01-15 | 2025-02-12 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2025-01-15 | 2025-02-12 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2025-01-15 | 2025-02-12 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2025-01-15 | 2025-02-12 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2025-01-15 | 2025-02-12 | 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 | 2025-01-15 | 2025-02-12 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2024-10-10 | 2024-11-11 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-10-10 | 2024-11-11 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-02-01 | 2024-02-29 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-02-01 | 2024-02-29 | Y |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2024-02-01 | 2024-02-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-01 | 2024-02-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-16 | 2024-02-20 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-01-16 | 2024-02-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-16 | 2024-02-20 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-01-16 | 2024-02-20 | Y |
| 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 |