Deficiency Records for Aspen Point Health and Rehabilitation
Updated as of March 01, 2021
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? |
|---|---|---|---|---|
| Use approved construction type or materials. | Fire Safety | 2020-10-13 | 2020-11-13 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2020-10-13 | 2020-11-13 | 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 | 2020-10-13 | 2020-11-13 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-10-13 | 2020-11-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-10-13 | 2020-11-13 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-10-13 | 2020-11-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-10-13 | 2020-11-13 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-10-13 | 2020-11-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-10-13 | 2020-11-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-10-13 | 2020-11-13 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2020-10-13 | 2020-11-13 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2020-10-13 | 2020-11-13 | 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 | 2020-10-13 | 2020-11-13 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2020-10-13 | 2020-11-13 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2020-10-13 | 2020-11-13 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-10-13 | 2020-11-13 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-10-13 | 2020-11-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-10-13 | 2020-11-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-10-13 | 2020-11-13 | 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 | 2020-10-13 | 2020-11-13 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2020-10-13 | 2020-11-13 | N |
| Post nurse staffing information every day. | Health | 2020-10-13 | 2020-11-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-10-13 | 2020-11-13 | 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 | 2020-10-13 | 2020-11-13 | 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 | 2020-10-13 | 2020-11-13 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-10-13 | 2020-11-13 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-10-13 | 2020-11-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-10-13 | 2020-11-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-10-13 | 2020-11-13 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2020-10-13 | 2020-11-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-06-30 | 2020-08-27 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2020-03-12 | 2020-08-04 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-03-12 | 2020-08-04 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-03-12 | 2020-08-04 | 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 | 2020-03-12 | 2020-08-04 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2020-03-12 | 2020-08-04 | 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 | 2020-03-12 | 2020-08-04 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-03-12 | 2020-08-04 | Y |
| 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 |
