Deficiency Records for Aspen Point Health and Rehabilitation
Updated as of September 01, 2020
This is not the most recent data for Aspen Point Health and Rehabilitation. For the most recent information, click here.
A list of the most recent deficiencies for Aspen Point Health and Rehabilitation. 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? |
|---|---|---|---|---|
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-08-14 | 2020-01-07 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-11-04 | 2020-01-07 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-11-04 | 2019-12-16 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-11-04 | 2019-12-16 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-11-04 | 2019-12-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-11-04 | 2019-12-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-11-04 | 2019-12-16 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-11-04 | 2019-12-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-04 | 2019-12-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-11-04 | 2019-12-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-11-04 | 2019-12-16 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-11-04 | 2019-12-16 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-11-04 | 2019-12-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-11-04 | 2019-12-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-07-26 | 2019-12-16 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-11-04 | 2019-12-16 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-11-04 | 2019-12-16 | 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 | 2019-11-04 | 2019-12-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-11-04 | 2019-12-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-04 | 2019-12-16 | 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 | 2019-11-04 | 2019-12-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-11-04 | 2019-12-16 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-11-04 | 2019-12-16 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-11-04 | 2019-12-16 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-11-04 | 2019-12-16 | 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 | 2019-11-04 | 2019-12-16 | N |
| 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 | 2019-11-04 | 2019-12-16 | 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 | 2019-11-04 | 2019-12-16 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-11-04 | 2019-12-16 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2019-11-04 | 2019-12-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-04 | 2019-12-16 | N |
| 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 | 2019-11-04 | 2019-12-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-04 | 2019-12-16 | N |
| Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. | Health | 2019-11-04 | 2019-12-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-10-02 | 2019-10-25 | Y |
| Respond appropriately to all alleged violations. | Health | 2019-10-02 | 2019-10-25 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-09-11 | 2019-10-18 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-07-26 | 2019-08-20 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-03-27 | 2019-05-06 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2019-03-27 | 2019-05-06 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-09-21 | 2018-10-26 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2018-09-21 | 2018-10-26 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-09-21 | 2018-10-26 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-09-21 | 2018-10-26 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-09-21 | 2018-10-26 | N |
| Install proper backup exit lighting. | Fire Safety | 2018-09-21 | 2018-10-26 | N |
| Have protected exits that allow the resident to escape the building. | Fire Safety | 2018-09-21 | 2018-10-26 | 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 | 2018-09-21 | 2018-10-26 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-09-21 | 2018-10-26 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-09-21 | 2018-10-26 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-09-21 | 2018-10-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-09-21 | 2018-10-26 | 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 | 2018-09-21 | 2018-10-26 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2018-09-21 | 2018-10-26 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-09-21 | 2018-10-26 | 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 | 2018-09-21 | 2018-10-26 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-09-21 | 2018-10-26 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-09-21 | 2018-10-26 | N |
| Provide activities to meet all resident's needs. | Health | 2018-09-21 | 2018-10-26 | 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 | 2018-09-21 | 2018-10-26 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-09-21 | 2018-10-26 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2018-09-21 | 2018-10-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-09-21 | 2018-10-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-09-21 | 2018-10-26 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-09-21 | 2018-10-26 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2018-04-04 | 2018-05-01 | 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 | 2018-04-04 | 2018-05-01 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-03-15 | 2018-04-13 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-03-15 | 2018-04-13 | Y |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-10-20 | 2017-11-13 | Y |
| Use approved construction type or materials. | Fire Safety | 2017-08-03 | 2017-09-01 | 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 | 2017-08-03 | 2017-09-01 | 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 | 2017-08-03 | 2017-09-01 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2017-08-03 | 2017-09-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-08-03 | 2017-09-01 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2017-08-03 | 2017-09-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-08-03 | 2017-09-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-08-03 | 2017-09-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-08-03 | 2017-09-01 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2017-08-03 | 2017-09-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-08-03 | 2017-09-01 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2017-08-03 | 2017-09-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-08-03 | 2017-09-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-08-03 | 2017-09-01 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2017-08-03 | 2017-09-01 | N |
| Upon the death of a resident, convey the resident?s personal funds and an accounting of those funds to the appropriate party. | Health | 2017-08-03 | 2017-09-01 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-08-03 | 2017-09-01 | N |
| Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. | Health | 2017-08-03 | 2017-09-01 | N |
| Provide housekeeping and maintenance services. | Health | 2017-08-03 | 2017-09-01 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-08-03 | 2017-09-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-08-03 | 2017-09-01 | N |
| Provide proper discharge planning and communication, of the resident's health status and summary of the resident's nursing home stay. | Health | 2017-08-03 | 2017-09-01 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-08-03 | 2017-09-01 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2017-08-03 | 2017-09-01 | N |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2017-08-03 | 2017-09-01 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-08-03 | 2017-09-01 | N |
| Post nurse staffing information/data on a daily basis. | Health | 2017-08-03 | 2017-09-01 | N |
| Provide a tasty and well-balanced diet that meets the nutritional needs of each resident. | Health | 2017-08-03 | 2017-09-01 | N |
| Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed. | Health | 2017-08-03 | 2017-09-01 | N |
| Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Health | 2017-08-03 | 2017-09-01 | N |
| 1) Provide 3 meals at regular times; 2) serve breakfast within 14 hours of dinner; and 3) offer a snack at bedtime each day. | Health | 2017-08-03 | 2017-09-01 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-08-03 | 2017-09-01 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-08-03 | 2017-09-01 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-08-03 | 2017-09-01 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2017-08-03 | 2017-09-01 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2017-08-03 | 2017-09-01 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2017-07-18 | 2017-08-31 | Y |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-07-18 | 2017-08-31 | Y |
| Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2017-07-18 | 2017-08-31 | Y |
