A list of the most recent deficiencies for Aspire Senior Living Oak Grove. 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? |
|---|---|---|---|---|
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-11-16 | 2023-05-17 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2022-11-16 | 2023-05-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-11-16 | 2023-05-17 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-11-16 | 2023-05-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-16 | 2023-05-17 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-02-23 | 2023-02-06 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-11-16 | 2022-12-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-16 | 2022-12-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-16 | 2022-12-31 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-11-16 | 2022-12-31 | N |
| Post nurse staffing information every day. | Health | 2022-11-16 | 2022-12-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-16 | 2022-12-31 | 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 | 2022-11-16 | 2022-12-31 | 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 | 2022-11-16 | 2022-12-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-16 | 2022-12-31 | N |
| Keep all essential equipment working safely. | Health | 2022-11-16 | 2022-12-31 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-11-16 | 2022-12-31 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-11-16 | 2022-12-31 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-11-16 | 2022-12-31 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-11-16 | 2022-12-31 | 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 | 2022-11-16 | 2022-12-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-16 | 2022-12-31 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-11-16 | 2022-12-31 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-11-16 | 2022-12-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-11-16 | 2022-12-31 | N |
| Meet Health Care Facilities Code mechanical requirements. | Fire Safety | 2022-11-16 | 2022-12-31 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-02-20 | 2020-04-02 | 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 | 2020-02-20 | 2020-04-02 | 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 | 2020-02-20 | 2020-04-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-20 | 2020-04-02 | N |
| Dispose of garbage and refuse properly. | Health | 2020-02-20 | 2020-04-02 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2020-02-20 | 2020-04-02 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2020-02-20 | 2020-04-02 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2020-02-20 | 2020-04-02 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2020-02-20 | 2020-04-02 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2020-02-20 | 2020-04-02 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-02-20 | 2020-04-02 | N |
| Meet Health Care Facilities Code mechanical requirements. | Fire Safety | 2020-02-20 | 2020-04-02 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-02-20 | 2020-04-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-20 | 2020-04-02 | 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 | 2019-05-15 | 2019-06-25 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-05-15 | 2019-06-25 | 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 | 2019-05-15 | 2019-06-25 | 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 | 2019-05-15 | 2019-06-25 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-05-15 | 2019-06-25 | 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 | 2019-05-15 | 2019-06-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-15 | 2019-06-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-15 | 2019-06-25 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-05-15 | 2019-06-25 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-05-15 | 2019-06-25 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-05-15 | 2019-06-25 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-05-15 | 2019-06-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-05-15 | 2019-06-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-15 | 2019-06-25 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-05-15 | 2019-06-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-05-15 | 2019-06-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-05-15 | 2019-06-25 | N |
| Ensure that smoke control systems are tested and documented in accordance with established engineering principles. | Fire Safety | 2019-05-15 | 2019-06-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-05-15 | 2019-06-25 | N |
