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Deficiency Records for Access Mental Health

A list of the most recent deficiencies for Access Mental Health. 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 Access Mental Health. 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?
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-02-01 2024-02-29 Y
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. Health 2024-02-01 2024-02-29 Y
Administer the facility in a manner that enables it to use its resources effectively and efficiently. Health 2024-02-01 2024-02-29 Y
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Health 2024-02-01 2024-02-29 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2024-01-16 2024-02-20 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2024-01-16 2024-02-20 Y
Respond appropriately to all alleged violations. Health 2024-01-16 2024-02-20 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-01-16 2024-02-20 Y
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. Fire Safety 2023-07-19 2023-09-27 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2023-07-19 2023-09-27 N
Have properly located and lighted "Exit" signs. Fire Safety 2023-07-19 2023-09-27 N
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2023-07-19 2023-09-27 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2023-07-19 2023-09-27 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-07-19 2023-09-27 N
Install corridor and hallway doors that block smoke. Fire Safety 2023-07-19 2023-09-27 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2023-07-19 2023-09-27 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2023-07-19 2023-09-27 N
Have simulated fire drills held at unexpected times. Fire Safety 2023-07-19 2023-09-27 N
Ensure proper usage of power strips and extension cords. Fire Safety 2023-07-19 2023-09-27 N
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Health 2023-06-14 2023-07-14 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-06-14 2023-07-14 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2023-06-14 2023-07-14 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 2023-06-14 2023-07-14 N
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2023-06-14 2023-07-14 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-06-14 2023-01-31 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-07-21 2022-07-28 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-05-17 2022-06-02 Y
Establish an Emergency Preparedness Program (EP). Fire Safety 2022-02-01 2022-04-04 N
Develop Emergency Preparedness policies and procedures. Fire Safety 2022-02-01 2022-04-04 N
Develop a communication plan. Fire Safety 2022-02-01 2022-04-04 N
Establish emergency prep training and testing. Fire Safety 2022-02-01 2022-04-04 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2022-02-01 2022-04-04 N
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. Fire Safety 2022-02-01 2022-04-04 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2022-02-01 2022-04-04 N
Have properly located and lighted "Exit" signs. Fire Safety 2022-02-01 2022-04-04 N
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2022-02-01 2022-04-04 N
Provide properly protected cooking facilities. Fire Safety 2022-02-01 2022-04-04 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2022-02-01 2022-04-04 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2022-02-01 2022-04-04 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2022-02-01 2022-04-04 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2022-02-01 2022-04-04 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2022-02-01 2022-04-04 N
Provide a written emergency evacuation plan. Fire Safety 2022-02-01 2022-04-04 N
Have simulated fire drills held at unexpected times. Fire Safety 2022-02-01 2022-04-04 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2022-02-01 2022-04-04 N
Ensure proper usage of power strips and extension cords. Fire Safety 2022-02-01 2022-04-04 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 2022-01-14 2022-02-28 N
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Health 2022-01-14 2022-02-28 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 2022-01-14 2022-02-28 N
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. Health 2022-01-14 2022-02-28 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-01-14 2022-02-28 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-01-14 2022-02-28 N
Provide and implement an infection prevention and control program. Health 2022-01-14 2022-02-28 N
Report COVID19 data to residents and families. Health 2022-01-14 2022-02-28 N
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Health 2022-01-14 2022-02-28 N
Have enough outside ventilation via a window or mechanical ventilation, or both. Health 2022-01-14 2022-02-28 N
Honor the resident's right to manage his or her financial affairs. Health 2022-01-14 2022-02-28 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 2021-11-03 2021-12-10 Y
Administer the facility in a manner that enables it to use its resources effectively and efficiently. Health 2021-11-03 2021-12-10 Y
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 2021-11-03 2021-12-10 Y
Keep all essential equipment working safely. Health 2021-11-03 2021-12-10 Y
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Health 2020-08-20 2020-09-30 N
Honor the resident's right to manage his or her financial affairs. Health 2020-08-20 2020-09-30 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 2020-08-20 2020-09-30 N
Ensure each resident receives an accurate assessment. Health 2020-08-20 2020-09-30 N
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2020-08-20 2020-09-30 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2020-08-20 2020-09-30 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 2020-08-20 2020-09-30 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2020-08-20 2020-09-30 N
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Health 2020-08-20 2020-09-30 N
Provide medically-related social services to help each resident achieve the highest possible quality of life. Health 2020-08-20 2020-09-30 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2020-08-20 2020-09-30 N
Provide and implement an infection prevention and control program. Health 2020-08-20 2020-09-30 N
Implement a program that monitors antibiotic use. Health 2020-08-20 2020-09-30 N
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Health 2020-08-20 2020-09-30 N
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2020-01-13 2020-02-15 N
Include a process for Emergency Preparedness collaboration. Fire Safety 2020-01-13 2020-02-15 N
Address subsistence needs for staff and patients. Fire Safety 2020-01-13 2020-02-15 N
Establish procedures for tracking staff and patients during an emergency. Fire Safety 2020-01-13 2020-02-15 N
Establish roles under a Waiver declared by secretary. Fire Safety 2020-01-13 2020-02-15 N
Conduct testing and exercise requirements. Fire Safety 2020-01-13 2020-02-15 N
Use approved construction type or materials. Fire Safety 2020-01-13 2020-02-15 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2020-01-13 2020-02-15 N
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. Fire Safety 2020-01-13 2020-02-15 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2020-01-13 2020-02-15 N
Have properly located and lighted "Exit" signs. Fire Safety 2020-01-13 2020-02-15 N
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2020-01-13 2020-02-15 N
Provide properly protected cooking facilities. Fire Safety 2020-01-13 2020-02-15 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2020-01-13 2020-02-15 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2020-01-13 2020-02-15 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2020-01-13 2020-02-15 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2020-01-13 2020-02-15 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2020-01-13 2020-02-15 N
Provide a written emergency evacuation plan. Fire Safety 2020-01-13 2020-02-15 N
Have simulated fire drills held at unexpected times. Fire Safety 2020-01-13 2020-02-15 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2020-01-13 2020-02-15 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2020-01-13 2020-02-15 N
Ensure proper usage of power strips and extension cords. Fire Safety 2020-01-13 2020-02-15 N
Have proper medical gas storage and administration areas. Fire Safety 2020-01-13 2020-02-15 N

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