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Deficiency Records for Aspire at Bryan Dairy
A list of the most recent deficiencies for Aspire at Bryan Dairy. 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 Bryan Dairy. 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? |
|---|---|---|---|---|
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-06-13 | 2024-09-07 | 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 | 2024-06-12 | 2024-07-12 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2024-06-12 | 2024-07-12 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-06-12 | 2024-07-12 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-06-12 | 2024-07-12 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-06-12 | 2024-07-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-06-12 | 2024-07-12 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2024-06-12 | 2024-07-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-06-12 | 2024-07-12 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-06-12 | 2024-07-12 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-06-12 | 2024-07-12 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-06-12 | 2024-07-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-06-12 | 2024-07-12 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-06-12 | 2024-07-12 | Y |
| 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 | 2024-06-12 | 2024-07-12 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-06-12 | 2024-07-12 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-06-12 | 2024-07-12 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-06-12 | 2024-07-12 | Y |
| Meet other general requirements. | Fire Safety | 2024-06-13 | 2024-07-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-06-13 | 2024-07-12 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-06-13 | 2024-07-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-06-13 | 2024-07-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-06-13 | 2024-07-12 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-02-28 | 2024-03-29 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-02-28 | 2024-03-29 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2024-02-28 | 2024-03-29 | Y |
| 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 | 2024-02-28 | 2024-03-29 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-11-03 | 2022-12-03 | 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 | 2022-11-03 | 2022-12-03 | Y |
| 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 | 2022-11-03 | 2022-12-03 | 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 | 2022-11-03 | 2022-12-03 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-03 | 2022-12-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-01 | 2022-07-02 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-04-01 | 2022-05-01 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-04-01 | 2022-05-01 | N |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2022-04-01 | 2022-05-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-01 | 2022-05-01 | 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 | 2022-04-01 | 2022-05-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-04-01 | 2022-05-01 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-04-01 | 2022-05-01 | 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 | 2022-05-01 | N |
| 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 | N |
| Dispose of garbage and refuse properly. | Health | 2022-04-01 | 2022-05-01 | 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 | 2022-04-01 | 2022-05-01 | Y |
| 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 | 2022-04-01 | 2022-05-01 | Y |
| Post nurse staffing information every day. | Health | 2022-04-01 | 2022-05-01 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-04-01 | 2022-05-01 | 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 | 2022-04-01 | 2022-05-01 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-11-18 | 2021-12-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-18 | 2021-12-17 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-18 | 2021-12-17 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-18 | 2021-12-17 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-01-29 | 2021-02-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-01-29 | 2021-02-26 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-01-29 | 2021-02-26 | 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 | 2021-01-29 | 2021-02-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-01-29 | 2021-02-26 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-01-27 | 2021-02-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-01-27 | 2021-02-26 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-01-27 | 2021-02-26 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-01-27 | 2021-02-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-01-27 | 2021-02-26 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2021-01-27 | 2021-02-26 | N |
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