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Deficiency Records for Aspire of Lake Park
A list of the most recent deficiencies for Aspire of Lake Park. 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 Lake Park. 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? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-18 | 2024-04-23 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2024-03-18 | 2024-04-19 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2024-03-21 | 2024-04-18 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2024-03-21 | 2024-04-18 | 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 | 2024-03-21 | 2024-04-18 | 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 | 2024-03-21 | 2024-04-18 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2024-03-21 | 2024-04-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-03-21 | 2024-04-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-03-21 | 2024-04-18 | 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 | 2024-03-21 | 2024-04-18 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2024-03-21 | 2024-04-18 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-03-21 | 2024-04-18 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2024-03-21 | 2024-04-18 | N |
| Post nurse staffing information every day. | Health | 2024-03-21 | 2024-04-18 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-03-21 | 2024-04-18 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2024-03-21 | 2024-04-18 | 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 | 2024-03-21 | 2024-04-18 | 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 | 2024-03-21 | 2024-04-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-21 | 2024-04-18 | N |
| Dispose of garbage and refuse properly. | Health | 2024-03-21 | 2024-04-18 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-03-21 | 2024-04-18 | N |
| Provide a neutral and fair arbitration process and agree to arbitrator and venue. | Health | 2024-03-21 | 2024-04-18 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2024-03-21 | 2024-04-18 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2024-03-21 | 2024-04-18 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-03-21 | 2024-04-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-21 | 2024-04-18 | Y |
| 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 | 2024-03-21 | 2024-04-18 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2024-03-21 | 2024-04-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-03-21 | 2024-04-18 | 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 | 2024-03-21 | 2024-04-18 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2024-03-18 | 2024-04-16 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-03-18 | 2024-04-12 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-03-18 | 2024-04-12 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2024-03-18 | 2024-04-11 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-03-18 | 2024-04-11 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-03-18 | 2024-04-11 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-03-18 | 2024-04-11 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-03-18 | 2024-04-11 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-03-18 | 2024-04-11 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-03-18 | 2024-04-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-03-18 | 2024-04-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-03-18 | 2024-04-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-03-18 | 2024-04-08 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-03-21 | 2024-04-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-03-18 | 2024-04-04 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-01-31 | 2023-02-24 | 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 | 2023-01-31 | 2023-02-24 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-01-31 | 2023-02-24 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-01-31 | 2023-02-24 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-01-31 | 2023-02-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-31 | 2023-02-24 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-01-31 | 2023-02-24 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-01-31 | 2023-02-24 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-01-31 | 2023-02-24 | N |
| Post nurse staffing information every day. | Health | 2023-01-31 | 2023-02-24 | N |
| 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 | 2023-01-31 | 2023-02-24 | 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 | 2023-01-31 | 2023-02-24 | 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 | 2023-01-31 | 2023-02-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-31 | 2023-02-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-31 | 2023-02-24 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-01-31 | 2023-02-24 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-01-31 | 2023-02-24 | 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 | 2023-01-31 | 2023-02-24 | 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 | 2023-01-31 | 2023-02-24 | Y |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-01-30 | 2023-02-09 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-01-30 | 2023-02-08 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-01-30 | 2023-02-06 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-01-30 | 2023-02-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-01-30 | 2023-02-06 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-01-30 | 2023-02-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-01-30 | 2023-02-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-01-30 | 2023-01-30 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-01-30 | 2023-01-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-31 | 2022-12-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-20 | 2022-10-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-20 | 2022-10-20 | 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 | 2021-10-07 | 2021-11-09 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-10-07 | 2021-11-09 | N |
| 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 | 2021-10-07 | 2021-11-09 | N |
| Assess the resident when there is a significant change in condition | Health | 2021-10-07 | 2021-11-09 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-10-07 | 2021-11-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-07 | 2021-11-09 | 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 | 2021-10-07 | 2021-11-09 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-10-07 | 2021-11-09 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-10-07 | 2021-11-09 | N |
| Post nurse staffing information every day. | Health | 2021-10-07 | 2021-11-09 | 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 | 2021-10-07 | 2021-11-09 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-10-07 | 2021-11-09 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-10-07 | 2021-11-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-07 | 2021-11-09 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-09-29 | 2021-11-09 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-09-29 | 2021-11-09 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-09-29 | 2021-11-09 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-09-29 | 2021-11-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-09-29 | 2021-11-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-29 | 2021-11-09 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-09-29 | 2021-11-09 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-09-29 | 2021-11-08 | N |
| Use approved construction type or materials. | Fire Safety | 2021-09-29 | 2021-10-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-09-29 | 2021-10-18 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-09-29 | 2021-10-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-09-29 | 2021-10-06 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2021-09-29 | 2021-10-06 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-09-29 | 2021-09-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-09-29 | 2021-09-30 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2024-09-24 | Not Fixed | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2024-09-24 | Not Fixed | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2024-09-24 | Not Fixed | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-09-24 | Not Fixed | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-09-24 | Not Fixed | Y |
| Respond appropriately to all alleged violations. | Health | 2024-09-24 | Not Fixed | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-09-24 | Not Fixed | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-09-24 | Not Fixed | Y |
| Provide activities to meet all resident's needs. | Health | 2024-09-24 | Not Fixed | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-09-24 | Not Fixed | Y |
| 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 | 2024-09-24 | Not Fixed | 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 | 2024-09-24 | Not Fixed | 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 | 2024-09-24 | Not Fixed | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-09-24 | Not Fixed | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2024-09-24 | Not Fixed | 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 | 2024-09-24 | Not Fixed | 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 | 2024-09-24 | Not Fixed | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-09-24 | Not Fixed | 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 | 2024-09-24 | Not Fixed | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-09-24 | Not Fixed | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-09-24 | Not Fixed | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-09-24 | Not Fixed | Y |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2024-09-24 | Not Fixed | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-09-24 | Not Fixed | Y |
| Keep all essential equipment working safely. | Health | 2024-09-24 | Not Fixed | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-09-24 | Not Fixed | Y |
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