A list of the most recent deficiencies for Ayden Healthcare of Belle Springs.. 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? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2023-10-04 | 2023-11-07 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2023-05-04 | 2023-05-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-21 | 2023-04-21 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-03-21 | 2023-04-21 | Y |
| 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 | 2022-11-04 | 2022-12-23 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-11-04 | 2022-12-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-04 | 2022-12-23 | 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 | 2022-11-04 | 2022-12-23 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-11-04 | 2022-12-23 | Y |
| 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 | 2022-11-04 | 2022-12-23 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-11-04 | 2022-12-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-11-04 | 2022-12-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-11-04 | 2022-12-23 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-11-04 | 2022-12-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-11-04 | 2022-12-23 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-11-04 | 2022-12-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-11-04 | 2022-12-23 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-07-25 | 2022-08-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-25 | 2022-08-22 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-07-25 | 2022-08-22 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-07-25 | 2022-08-22 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-07-25 | 2022-08-22 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-07-25 | 2022-08-22 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-04-19 | 2021-04-20 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-10-24 | 2019-11-29 | 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 | 2019-10-24 | 2019-11-29 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-10-24 | 2019-11-29 | 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 | 2019-10-24 | 2019-11-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-10-21 | 2019-11-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-21 | 2019-11-29 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-10-21 | 2019-11-29 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-10-21 | 2019-11-29 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-10-21 | 2019-11-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-21 | 2019-11-29 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2018-08-29 | 2018-10-04 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-08-29 | 2018-10-04 | 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 | 2018-08-29 | 2018-10-04 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-08-29 | 2018-10-04 | 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 | 2018-08-29 | 2018-10-04 | 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 | 2018-08-29 | 2018-10-04 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2018-08-29 | 2018-10-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-08-29 | 2018-10-04 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-08-29 | 2018-10-04 | 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 | 2018-08-29 | 2018-10-04 | 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 | 2018-08-29 | 2018-10-04 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-08-29 | 2018-10-04 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-08-22 | 2018-10-04 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-08-22 | 2018-10-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-08-22 | 2018-10-04 | N |
