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Deficiency Records for Aspire at The Bay
A list of the most recent deficiencies for Aspire at The Bay. 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 Bay. 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? |
|---|---|---|---|---|
| Keep residents' personal and medical records private and confidential. | Health | 2024-06-28 | 2024-07-26 | 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 | 2024-06-28 | 2024-07-26 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-06-28 | 2024-07-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-06-28 | 2024-07-26 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2024-06-28 | 2024-07-26 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-06-28 | 2024-07-26 | N |
| Provide activities to meet all resident's needs. | Health | 2024-06-28 | 2024-07-26 | 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 | 2024-06-28 | 2024-07-26 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-06-28 | 2024-07-26 | 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 | 2024-06-28 | 2024-07-26 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2024-06-28 | 2024-07-26 | N |
| Provide or obtain dental services for each resident. | Health | 2024-06-28 | 2024-07-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-06-28 | 2024-07-26 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-06-28 | 2024-07-26 | 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 | 2024-06-28 | 2024-07-26 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-06-28 | 2024-07-26 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-06-28 | 2024-07-26 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-06-28 | 2024-07-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-06-28 | 2024-07-26 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-06-28 | 2024-07-26 | Y |
| Meet other general requirements. | Fire Safety | 2024-06-26 | 2024-07-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-06-26 | 2024-07-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-06-26 | 2024-07-26 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-01-12 | 2024-02-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-12 | 2024-02-09 | 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 | 2022-10-24 | 2022-11-24 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-10-24 | 2022-11-24 | Y |
| Post nurse staffing information every day. | Health | 2022-08-30 | 2022-09-08 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-04-01 | 2022-05-26 | 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 | 2022-04-01 | 2022-05-26 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-04-01 | 2022-05-26 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2022-04-01 | 2022-05-01 | 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 | 2022-04-01 | 2022-05-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-01 | 2022-05-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-04-01 | 2022-05-01 | N |
| Keep all essential equipment working safely. | Health | 2022-04-01 | 2022-05-01 | N |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2022-04-01 | 2022-05-01 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-01 | 2022-05-01 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-03-30 | 2022-05-01 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-03-30 | 2022-05-01 | N |
| Develop a communication plan. | Fire Safety | 2022-03-30 | 2022-05-01 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-03-30 | 2022-05-01 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-03-30 | 2022-05-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-02-11 | 2021-03-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-02-11 | 2021-03-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-02-11 | 2021-03-12 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-02-11 | 2021-03-12 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-02-11 | 2021-03-12 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-02-11 | 2021-03-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-02-11 | 2021-03-12 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-02-12 | 2021-03-08 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-02-12 | 2021-03-08 | 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 | 2021-02-12 | 2021-03-08 | N |
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