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 |