Aspire Physical Recovery Center at Hoover, LLC

Inspectors wroteBased on interviews, record review, facility document reviews, review of facility policies titled Medication Administration - General Guidelines and Documentation for Medication Administration, the facility failed to prevent significant medication errors for Residents #299 and #143, two of six residents reviewed for medication administration. The nursing staff failed to administer five morning doses of Resident #299's ordered anticonvulsant medication, Vimpat, from 05/26/2023 to 06/01/2023. On 06/04/2023 Resident #299 had a seizure and was transferred to a hospital for further treatment. In addition, the nursing staff failed to administer insulin as ordered for Resident #143. On 03/20/2023, Resident #143 was found to have a blood glucose level greater than 500 milligrams per deciliter (mg/dL) and was transferred to an emergency department. [...]

Inspectors wroteBased on interviews, record review, and facility document and policy review, it was determined the facility failed to provide care and treatment in accordance with professional standards of practice to meet the needs of five (Residents #98, #141, #454, #112, and #300) of 50 sampled residents. Specifically, the facility failed to: 1. Obtain orders for the care and monitoring of a peripherally inserted central catheter (PICC) line for Resident #98; 2. Transcribe orders for care of a surgical wound for Resident #141; 3. Ensure care of a surgical wound was completed as ordered for Resident #112; and 4. Ensure coordination between the facility and Resident #300's hospice provider regarding who would provide the resident's medications while in the facility for respite care (generally a short-term temporary admission, usually for residents receiving hospice benefits). [...]

Inspectors wroteBased on observations, interviews, record review, and facility policy review, it was determined that the facility failed to assess residents for the ability to self-administer medications for one (Resident #60) of four residents reviewed during medication pass observation.

Inspectors wroteBased on observations, interviews, record review, and review of facility policy titled Resident Assessment Instrument (RAI) , the facility failed to ensure one (Resident #1) of one resident was assessed for appropriate adaptive equipment related to call lights.

Inspectors wroteBased on interviews, record review, and facility policy titled Discharge Summary and Plan of Care, it was determined that the facility failed to have a completed discharge summary with a recapitulation (concise summary) of the residents' stay for two (Resident #98 and Resident #453) of two residents reviewed for discharge requirements.

Inspectors wroteBased on interviews, record review, and facility policy review, it was determined that the facility failed to ensure medications were available from the pharmacy for two (Resident #452 and Resident #142) of six residents reviewed for unnecessary medications. Specifically, the facility failed to ensure Resident #452's Prednisone and Resident #142's inhaler was available from the pharmacy for administration.

Inspectors wroteBased on observations, interviews, record review, facility document review, and facility policies titled Medication Administration-General Guidelines and Blood Glucose Testing the facility failed to ensure adequate monitoring of blood glucose (sugar) levels as ordered by the physician for the use of insulin for Resident #143 and #294, two of five residents reviewed for unnecessary medications.

Inspectors wroteBased on record review, the facility policy titled, Incidents and Accidents, and interviews, the facility failed to maintain medical records for residents that were complete and accurately documented for two (Resident #141 and Resident #106) of 27 sampled residents. Specifically, 1) the facility failed to document the administration of medications for Resident #141. 2) the facility failed to complete an incident report when Resident #106 was found on the floor on 04/18/2023.

Inspectors wroteBased on observations, interviews and review of facility policies, titled Leftover Food Storage and Use, Food Storage Temperature Logs, FOOD STORAGE TEMPERATURE LOG,' and Food from Families and Friends, the facility failed to ensure: 1. food in the kitchen freezer was labeled with an open and use by date, 2. PM temperatures were logged on 3/17/21 for the resident's supplement refrigerator on the 400 hall, and, 3. food item in the resident's supplement freezer was labeled. This had the potential to affect 73 of 73 residents who received meals from the kitchen and 30 residents who had the potential to utilize the supplement refrigerator on the 400 hall. Findings Include: 1. A review of a facility policy titled, Leftover Food Storage and Use with an Effective date of Sept. 12, 2019 revealed . Purpose: To Assure that food borne illnesses are avoided. PROCESS: . b. [...]

Inspectors wroteBased on observation, interviews and review of a policy titled Perineal Care, the facility failed to ensure a Certified Nursing Assistant (CNA), changed her gloves during incontinent care before placing the clean brief for Resident Identifier (RI) #9. This affected one of two residents observed for incontinent care. Findings Include: A review of a facility policy Perineal Care with an effective date of 10/1/2010, revealed: PURPOSE: Good perineal care helps prevent infection, irritation and skin breakdowns. RI #9 was admitted to the facility on [DATE] with a diagnosis of Personal History of Urinary Tract Infections. On 3/18/21 at 3:08 PM, Employee Identifier (EI) #4, CNA, entered RI #9's room for the provision of incontinent care. EI #4 lowered the head of the bed, explained the procedure, washed her hands and donned gloves. EI #4 removed the soiled brief and provided the perineal care. [...]

Inspectors wroteBased on observation, interview, and review of the facility policy titled Food Receipt and Storage and the 2017 FDA Food Code, the facility failed to ensure: 1. staff placed a large pan of frozen crab cake meat on the shelf, off of the floor in the walk in freezer; 2. food items in the walk-in freezer and reach-in freezer were sealed; and 3. a dented can of baked beans was removed from active service storage. This had the potential to affect 106 out of 106 residents receiving meals from the kitchen.

Inspectors wroteBased on record review, interview, and review of a facility policy titled, Disposal of Medications Non-Controlled Medication Destruction, the facility failed to ensure the required signatures were on nine of nine Non-Controlled Record of Medication Destruction Sheets for the month of February, 2020. This affected one of five months of Non-Controlled Medication Destruction Records reviewed. Findings Include: Review of a facility policy titled, Disposal of Medications Non-Controlled Medication Destruction, dated 3/2011, revealed: . 3. The registered nurse and/or pharmacist witnessing the destruction ., ensures that the following information is entered on the Record of Medication Destruction form . J. Signature of witnesses, two witnesses required for non-controlled substances . in the designated areas on the destruction form. [...]