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Deficiency Records for Aspire of Donnellson
A list of the most recent deficiencies for Aspire of Donnellson. 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 of Donnellson. 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 appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-04-01 | 2024-04-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-20 | 2024-04-05 | Y |
| Honor the resident's right to choose his or her attending physician. | Health | 2024-02-20 | 2024-03-21 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-20 | 2024-03-21 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-02-20 | 2024-03-21 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-02-20 | 2024-03-21 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-02-20 | 2024-03-21 | 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 | 2024-02-20 | 2024-03-21 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-02-20 | 2024-03-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-20 | 2024-03-21 | 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 | 2024-02-20 | 2024-03-21 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2024-02-20 | 2024-03-21 | Y |
| 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 | 2024-02-20 | 2024-03-21 | Y |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2024-02-20 | 2024-03-21 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-02-20 | 2024-03-21 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2024-02-20 | 2024-03-21 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2024-02-20 | 2024-03-21 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-02-20 | 2024-03-21 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-02-20 | 2024-03-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-02-20 | 2024-03-21 | Y |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2024-02-20 | 2024-03-21 | Y |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2024-02-20 | 2024-03-21 | Y |
| Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | Health | 2024-02-20 | 2024-03-21 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2024-02-20 | 2024-03-21 | Y |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2024-02-20 | 2024-03-21 | Y |
| Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. | Health | 2024-02-20 | 2024-03-21 | Y |
| Provide training in compliance and ethics. | Health | 2024-02-20 | 2024-03-21 | Y |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2024-02-20 | 2024-03-21 | Y |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-11-15 | 2023-12-15 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-11-09 | 2023-12-10 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-11-09 | 2023-12-10 | N |
| 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 | 2023-11-09 | 2023-12-10 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2023-11-09 | 2023-12-10 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-11-09 | 2023-12-10 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-11-09 | 2023-12-10 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-11-09 | 2023-12-10 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-11-09 | 2023-12-10 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-11-09 | 2023-12-10 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-09 | 2023-12-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-09 | 2023-12-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-09 | 2023-12-10 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-11-15 | 2023-11-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-15 | 2023-11-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-15 | 2023-11-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-15 | 2023-11-28 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-11-15 | 2023-11-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-06-30 | 2022-07-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-30 | 2022-07-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-30 | 2022-07-20 | 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 | 2022-06-30 | 2022-07-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-30 | 2022-07-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-30 | 2022-07-20 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-06-30 | 2022-07-18 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-06-30 | 2022-07-18 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-06-30 | 2022-07-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-30 | 2022-07-01 | Y |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-06-30 | 2022-07-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-06-30 | 2022-07-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-06-30 | 2022-07-01 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-06-30 | 2022-06-30 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-02-10 | 2022-02-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-10 | 2022-02-11 | 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 | 2022-02-10 | 2022-02-11 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-02-10 | 2022-02-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-18 | 2021-11-19 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-10-25 | 2021-11-19 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-25 | 2021-11-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-25 | 2021-11-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-25 | 2021-11-19 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-10-25 | 2021-11-19 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-10-25 | 2021-11-19 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-10-25 | 2021-11-19 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2021-10-25 | 2021-11-19 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-10-25 | 2021-11-19 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-02-26 | 2020-03-24 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2020-02-20 | 2020-03-13 | 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 | 2020-02-20 | 2020-03-13 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2020-02-26 | 2020-03-11 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-02-26 | 2020-03-10 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-02-26 | 2020-03-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-02-26 | 2020-02-26 | N |
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