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Deficiency Records for Aspire at Colonial Lakes

A list of the most recent deficiencies for Aspire at Colonial Lakes. 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 Colonial Lakes. 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?
Help the resident make transportation arrangements to and from radiology services. Health 2024-09-06 2024-10-03 Y
Allow residents to self-administer drugs if determined clinically appropriate. Health 2024-07-18 2024-08-14 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 2024-07-18 2024-08-14 N
Assist a resident in gaining access to vision and hearing services. Health 2024-07-18 2024-08-14 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2024-07-18 2024-08-14 N
Provide and implement an infection prevention and control program. Health 2024-07-18 2024-08-14 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2024-07-18 2024-08-14 N
Keep all essential equipment working safely. Health 2024-07-18 2024-08-14 N
Meet other general requirements. Fire Safety 2024-07-17 2024-08-08 N
Use approved construction type or materials. Fire Safety 2024-07-17 2024-08-08 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 2024-07-17 2024-08-08 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2024-07-17 2024-08-08 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2024-07-17 2024-08-08 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 2023-03-08 2023-04-07 Y
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 2023-03-08 2023-04-07 Y
Allow residents to self-administer drugs if determined clinically appropriate. Health 2023-01-05 2023-02-05 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-01-05 2023-02-05 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2023-01-05 2023-02-05 Y
Post nurse staffing information every day. Health 2022-12-01 2023-01-01 Y
Honor the resident's right to manage his or her financial affairs. Health 2022-08-18 2022-09-19 N
Provide doctor's orders for the resident's immediate care at the time the resident was admitted. Health 2022-08-18 2022-09-19 N
Ensure each resident receives an accurate assessment. Health 2022-08-18 2022-09-19 N
PASARR screening for Mental disorders or Intellectual Disabilities Health 2022-08-18 2022-09-19 N
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2022-08-18 2022-09-19 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2022-08-18 2022-09-19 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 2022-08-18 2022-09-19 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2022-08-18 2022-09-19 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-08-18 2022-09-19 N
Provide safe, appropriate dialysis care/services for a resident who requires such services. Health 2022-08-18 2022-09-19 N
Ensure that residents are free from significant medication errors. Health 2022-08-18 2022-09-19 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-08-18 2022-09-19 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2022-08-18 2022-09-19 N
Provide and implement an infection prevention and control program. Health 2022-08-18 2022-09-19 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 2022-08-18 2022-09-19 Y
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 2022-08-17 2022-09-19 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2022-08-17 2022-09-19 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2022-08-17 2022-09-19 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2022-08-17 2022-09-19 N
Have proper medical gas storage and administration areas. Fire Safety 2022-08-17 2022-09-19 N
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Health 2022-01-23 2022-02-23 Y
Allow residents to self-administer drugs if determined clinically appropriate. Health 2021-01-28 2021-02-28 N
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Health 2021-01-28 2021-02-28 N
Ensure each resident receives an accurate assessment. Health 2021-01-28 2021-02-28 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2021-01-28 2021-02-28 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2021-01-28 2021-02-28 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2021-01-28 2021-02-28 N
Use approved construction type or materials. Fire Safety 2021-01-27 2021-02-28 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2021-01-27 2021-02-28 N
Install corridor and hallway doors that block smoke. Fire Safety 2021-01-27 2021-02-28 N
Provide a written emergency evacuation plan. Fire Safety 2021-01-27 2021-02-28 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2021-01-27 2021-02-28 N

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