Access Mental Health
Inspection History Overview
Detailed Inspection Reports
Notice: These are official CMS inspection narratives containing detailed regulatory findings. This information is not available in searchable format anywhere else online.
Fines and Penalties by Year
2022 21 penalties totaling $29,719
Fine
Fine
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Fine
Fine
Fine
Fine
Fine
Payment Denial
Fine
Fine
2021 44 penalties totaling $11,700
Fine
Fine
Fine
Fine
Fine
Fine
Fine
Fine
Fine
Fine
Fine
Fine
Fine
Fine
Fine
Fine
Fine
Fine
Fine
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Fine
Fine
Fine
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2020 10 penalties totaling $17,550
Fine
Fine
Fine
Fine
Fine
Fine
Fine
Fine
Payment Denial
Fine
Health Violations by Year
2025 17 violations
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.
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Ensure each resident receives an accurate assessment.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Provide enough food/fluids to maintain a resident's health.
Provide care or services that was trauma informed and/or culturally competent.
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Ensure each resident’s drug regimen must be free from unnecessary drugs.
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.
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.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Develop and implement policies and procedures for flu and pneumonia vaccinations.
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.
2024 8 violations
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Respond appropriately to all alleged violations.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
2023 6 violations
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide safe and appropriate respiratory care for a resident when needed.
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.
2022 13 violations
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Honor the resident's right to manage his or her financial affairs.
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.
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide and implement an infection prevention and control program.
Report COVID19 data to residents and families.
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Have enough outside ventilation via a window or mechanical ventilation, or both.
2021 8 violations
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.
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
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.
Keep all essential equipment working safely.
Respond appropriately to all alleged violations.
Honor the resident's right to manage his or her financial affairs.
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
2020 22 violations
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
PASARR screening for Mental disorders or Intellectual Disabilities
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
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.
Provide enough food/fluids to maintain a resident's health.
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Honor the resident's right to manage his or her financial affairs.
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.
Ensure each resident receives an accurate assessment.
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide and implement an infection prevention and control program.
Implement a program that monitors antibiotic use.
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
2019 20 violations
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Give residents a notice of rights, rules, services and charges.
Ensure residents have reasonable access to and privacy in their use of communication methods.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
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.
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Plan the resident's discharge to meet the resident's goals and needs.
Observe each nurse aide's job performance and give regular training.
Post nurse staffing information every day.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Ensure each resident’s drug regimen must be free from unnecessary drugs.
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.
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Dispose of garbage and refuse properly.
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.
Provide and implement an infection prevention and control program.
Implement a program that monitors antibiotic use.
2018 19 violations
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Honor the resident's right to manage his or her financial affairs.
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
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.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Plan the resident's discharge to meet the resident's goals and needs.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Plan the resident's discharge to meet the resident's goals and needs.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
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.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide and implement an infection prevention and control program.
Develop and implement policies and procedures for flu and pneumonia vaccinations.
2017 1 violations
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.
2016 1 violations
Have a program that investigates, controls and keeps infection from spreading.