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Deficiency Records for Aspire at The Palms
A list of the most recent deficiencies for Aspire at The Palms. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Aspire at The Palms. 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 and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-08-09 | 2024-09-09 | 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 | 2024-08-09 | 2024-09-09 | 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 | 2024-08-09 | 2024-09-09 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-08-09 | 2024-09-09 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2024-08-09 | 2024-09-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-08-09 | 2024-09-09 | 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 | 2024-08-09 | 2024-09-09 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2024-08-09 | 2024-09-09 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2024-08-07 | 2024-09-09 | 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 | 2024-08-07 | 2024-09-09 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-08-07 | 2024-09-09 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-08-07 | 2024-09-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-08-07 | 2024-09-09 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-08-07 | 2024-09-09 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-23 | 2023-04-25 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-03-23 | 2023-04-25 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-03-23 | 2023-04-25 | 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 | 2023-03-23 | 2023-04-25 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-03-23 | 2023-04-17 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-03-23 | 2023-04-17 | Y |
| 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 | 2023-03-23 | 2023-04-17 | Y |
| 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 | 2022-04-22 | 2022-07-19 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-04-22 | 2022-07-19 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-04-22 | 2022-07-19 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-06-30 | 2022-07-19 | Y |
| 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 | 2022-06-30 | 2022-07-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-30 | 2022-07-19 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-06-30 | 2022-07-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-22 | 2022-07-19 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-04-22 | 2022-07-19 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-04-22 | 2022-05-19 | 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 | 2022-04-22 | 2022-05-19 | 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 | 2022-04-22 | 2022-05-19 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-04-22 | 2022-05-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-22 | 2022-05-19 | 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 | 2022-04-22 | 2022-05-19 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-04-22 | 2022-05-19 | 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 | 2022-04-22 | 2022-05-19 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-22 | 2022-05-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-22 | 2022-05-19 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-22 | 2022-05-19 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-04-22 | 2022-05-19 | Y |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-04-19 | 2022-05-19 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-04-19 | 2022-05-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-04-19 | 2022-05-19 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-04-19 | 2022-05-19 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-02-18 | 2021-03-18 | 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 | 2021-02-18 | 2021-03-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-02-18 | 2021-03-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-02-18 | 2021-03-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-02-18 | 2021-03-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-02-18 | 2021-03-18 | N |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2021-02-18 | 2021-03-18 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-02-18 | 2021-03-18 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-02-16 | 2021-03-18 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-02-16 | 2021-03-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-02-16 | 2021-03-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-02-16 | 2021-03-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-02-16 | 2021-03-18 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-02-16 | 2021-03-18 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-02-16 | 2021-03-18 | N |
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