Deficiency Records for Aspen Meadows Health and Rehabilitation Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Aspen Meadows Health and Rehabilitation Center. 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-30 | 2023-05-08 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-03-30 | 2023-05-08 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-03-30 | 2023-05-08 | 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 | 2023-03-30 | 2023-05-08 | 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 | 2023-03-30 | 2023-05-08 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-03-30 | 2023-05-08 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-30 | 2023-05-08 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-03-30 | 2023-05-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-30 | 2023-05-08 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-03-30 | 2023-05-08 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-30 | 2023-05-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-03-30 | 2023-04-28 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-21 | 2023-04-17 | 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 | 2023-03-21 | 2023-04-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-21 | 2023-04-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-21 | 2023-04-17 | N |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2023-03-21 | 2023-04-17 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-03-21 | 2023-04-17 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-03-21 | 2023-04-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-21 | 2023-04-17 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-03-31 | 2022-05-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-03-31 | 2022-05-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-31 | 2022-05-15 | 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 | 2022-03-31 | 2022-05-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-31 | 2022-05-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-03-31 | 2022-05-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-31 | 2022-04-29 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-03-31 | 2022-04-24 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-03-08 | 2022-04-22 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-03-08 | 2022-04-22 | N |
| Develop a communication plan. | Fire Safety | 2022-03-08 | 2022-04-22 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-03-08 | 2022-04-22 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-03-08 | 2022-04-22 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-03-08 | 2022-04-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-03-08 | 2022-04-22 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-11-11 | 2021-12-24 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-11-11 | 2021-12-24 | 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 | 2021-11-11 | 2021-12-24 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-11 | 2021-12-24 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-11 | 2021-12-24 | 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 | 2021-11-11 | 2021-12-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-11 | 2021-12-24 | 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 | 2021-07-08 | 2021-08-09 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-04-19 | 2021-05-23 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2021-04-19 | 2021-05-23 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-04-19 | 2021-05-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-04-19 | 2021-05-23 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-04-19 | 2021-05-23 | 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 | 2021-04-13 | 2021-05-20 | N |
