Aspire Senior Living Advance

Inspectors wroteBased on interview and record review, the facility failed have an appropriate diagnosis for an antipsychotic (psychiatric medications used to manage psychosis, particularly hallucinations, delusions, and severe agitation) medication for one resident (Resident #16) and failed to limit an as needed (PRN) antipsychotic medication to 14 days for one resident (Resident #27) and out of 12 sampled residents. Facility census was 30. Review of the facility policy titled, Use of Psychotropic Medications, undated, showed:- A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include, but are not limited to the following categories: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders when administering a medication as ordered for one resident (Resident#18) out of 12 sampled residents and during wound care for one resident (Resident #26) out of three sampled residents. The facility census was 30. The facility did not provide a policy for following physician orders. 1. Review of Resident #18's medical record showed:- admitted on [DATE];- Diagnosis of type 2 diabetes mellitus (a chronic condition causing high blood sugar);- An order for Lantus (a long-acting insulin) 8 units subcutaneously (an injection under the skin) at bedtime related to type 2 diabetes mellitus, dated 10/27/25. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident diagnosed with dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) had a personalized plan of care to ensure services to promote the resident's highest level of functioning and psychosocial needs for two residents (Residents #5 and #27) out of three sampled residents with dementia. The facility census was 30. The facility did not provide a policy regarding dementia care. Review of the facility's policy titled, Comprehensive Care Plans, dated 2025, showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications and biologicals were labeled in accordance with currently accepted practices for one resident (Resident #27) for one out of one sampled medication cart and one out of one sampled medication room. This practice had the potential to affect all residents. The facility's census was 30. Review of the facility policy titled, Medication Labeling and Storage, undated, showed:- All medications and biologicals will be labeled in accordance with applicable federal and state requirements and current accepted pharmaceutical principles and practices;- Labels for multi-use vials must include the date the vial was initially opened;- All opened or accessed vials should be discarded within 28 days unless the manufacturer specifies a different date. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This had the potential to affect all residents. The facility census was 30. Review of the facility's policy titled, Cleaning, dated 01/30/24, showed: - All equipment, food contact surfaces, and utensils shall be cleaned each time there is a use with a different type of raw animal product, each time there is a change from working with raw foods to ready-to-eat foods, whenever contamination may have occurred;- All food surfaces will be cleaned at the end of each food preparation session;- Refrigerator units must be cleaned. Review of the facility's policy titled, Food Safety Requirements, undated, showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection prevention measures when staff did not properly disinfect the glucometer (a portable device used to measure blood sugar levels) for four residents (Residents #1, #4, #18, and #28) out of four sampled residents. The facility census was 30. Review of the facility policy titled, Glucometer Disinfection, undated, showed: - The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. Review of the manufacturer's guidelines titled, Quintet AC Blood Glucose Meter Owner's Manual, undated, showed: - The following cleaning and disinfecting steps to be performed after each use: - Thoroughly wipe the entire surface of the meter with disinfecting wipes to clean any possible dirt, blood, and other body fluids; [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer/discharge to a hospital, including the reasons for transfer, for three residents (Residents #1, #28 and #32) out of 12 sampled residents. The facility's census was 34. Review of the facility's policy titled, Discharge-Transfer of Resident, dated 03/2015, showed: - Explain transfer and reason to the resident and/or representative and give copy of signed transfer or discharge notice to the resident and/or representative or person responsible for care. If an emergency transfer, transfer or discharge notice form may be completed later, but as soon as possible. 1. Review of Resident #1's medical record showed: - The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; [...]

Inspectors wroteBased on interview and record review, the facility failed to inform the resident and/or the legal representative of their bed hold policy at the time of transfer to the hospital for three residents (Residents #1, #28 and #32) out of 12 sampled residents. The facility's census was 34. Review of the facility's policy titled, Bed Hold, undated, showed: - The facility will notify the resident at the time of admission and again prior to a hospital transfer or therapeutic leave of its bed-hold and return policies; - Before any transfer, advance notice of the policy is given, usually at the time of admission and also included in the admission packet. Re-issuance of the first notice is not required unless the facility's policy changes; [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, for three residents (Residents #6, #11, and #32) out of 12 sampled residents. The facility census was 34. The facility did not provide a policy regarding MDS accuracy. 1. Review of Resident #6's medical record showed: - An admission date of 08/21/24; - Diagnoses of hypertension (high blood pressure), diabetes mellitus (DM - a condition that affects the way the body processes blood sugar), convulsions (seizures - a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements like stiffness, twitching or limpness, behaviors, sensations, or states of awareness), and hypothyroidism (abnormal thyroid producing wrong amount of hormones); [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to appropriately assess the use of bed rails for four residents (Residents #1, #2, #7 and #28) out of 10 sampled residents and one resident (Resident #3) outside the sample. The facility census was 34. The facility did not provide a policy regarding bed rails. 1. Review of Resident #1's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by the facility), dated 11/01/24, showed: - Cognitively intact; - Required supervision with bed mobility; - The MDS did not indicate bed rail use. Review of the resident's care plan, revised 11/05/24, showed: - A risk of falls; - Addressed the resident's use of the bed rails. Review of the resident's medical record showed: - No documentation of bed rail assessments; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents diagnosed with dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) had a personalized plan of care to ensure appropriate services to promote the resident's highest level of functioning and psychosocial needs were provided for one resident (Residents #9) out of three sampled residents. The facility census was 34. The facility did not provide a policy regarding dementia care. 1. Review of Resident #9's medical record showed: - An admission date of 09/12/24; - Diagnoses of unspecified dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking) and cognitive communication deficit (difficulty communicating). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an appropriate diagnosis for the use of a psychotropic (a drug that affects the brain activities associated with mental processes and behavior) medication for two residents (Residents #9 and #11) out of 12 sampled residents and one resident (Resident #15) outside the sample. The facility census was 34. The facility did not provide a policy regarding appropriate diagnosis of a psychotropic medication. Review of AstraZeneca's Product Monograph for quetiapine, revised 11/29/21, showed: - Quetiapine is indicated for schizophrenia (a long term mental disorder that affects a person's ability to think, feel, or behave clearly, sometimes including delusions or hallucinations) and bipolar disorder (a mental disorder that causes unusual shifts in mood); [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a medication error rate of less than five percent (%). There were 27 opportunities with three errors made, resulting in an error rate of 11.11% for three residents (Residents #1, #8 and #32) out of 12 sampled residents. The facility's census was 34. Review of the facility policy titled, Insulin Pen Injections, undated, showed: - Attach safety needle, turn dose selector to two units and perform airshot (priming), then turn dose selector to required units for injection. 1. Review of Resident #1's medical record showed: - Diagnosis of type 2 diabetes mellitus (a condition in which the body has trouble controlling blood sugar and using it for energy); - An order for insulin lispro pen to be given with meals according to sliding scale, dated 05/22/24. Observation on 11/21/24 at 11:08 A.M., showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to label and store medications in a safe and effective manner. This had the potential to affect all residents. The facility census was 34. Review of the facility policy titled, Storage of Medications, undated, showed: - No discontinued or outdated medications are to be used and all such medications are destroyed; - Multi-dose vials that have been opened or accessed should be dated and discarded within 28 days of opening unless manufacturer specified a shorter or longer date. Review of the manufacturer's recommendations for Tubersol (a solution used for a tuberculosis (TB - a contagious lung disease) testing showed the medication was to be discarded 30 days after opening. Observation on 11/21/24 at 3:25 P.M., of the medication room refrigerator showed: - Two opened vials of Tubersol with no opened date. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain proper infection control practices while providing incontinent care, medication administration/tube feeding (a tube inserted into the abdomen to provide nutrition into the stomach), catheter (a tube inserted into the bladder to drain urine) care, and wound care for three residents (Resident #3, #16, and #237) out of four sampled residents and for one resident (Resident #17) outside the sample. The facility failed to ensure proper Tuberculosis (TB - a communicable disease that affects the lungs, characterized by fever, cough and difficulty breathing) screening of three residents (Residents #6, #12, and #16) out of five sampled residents. The facility's census was 34. Review of the facility's policy titled, Gloves, dated 03/2015, showed: [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to post, in a form and manner accessible to the residents and resident representatives, the required telephone number to the Department of Health and Senior Services (DHSS) hotline (to report allegations of abuse and neglect), or a list of names, addresses, and phone numbers of the State Survey Agency (SSA). The census was 34. The facility did not provide a policy. Observation of the facility on 11/19/24 through 11/21/24, showed the facility did not post the name, address and toll free telephone number for the DHSS Abuse and Neglect Hotline or the SSA information in a form and manner accessible to residents or visitors. During a group interview on 11/21/24 at 9:35 A.M., six residents (Residents #3, #6, #8, #20, #21, and #237) said they did not how to find the state hotline number and had not seen it posted. [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct at least twelve hours of nurse aide in-service education per year. This affected one out of two sampled Certified Nurse Assistants (CNA) (CNA B). The facility's census was 34. The facility did not provide a policy regarding in-service training. 1. Record review of CNA B's in-service record showed: - A hire date of 09/01/21; - A total of eight hours of annual in-service training for November 2023 through November 2024; - Less than twelve hours of in-service education for November 2023 through November 2024. During an interview on 11/21/24 at 8:30 A.M., the Director of Nursing (DON) said in-service training was conducted on a monthly basis and all CNA's were expected to attend at least 12 hours of in-service training annually. [...]

Inspectors wroteBased on interview and record review, the facility failed to have a Quality Assurance and Performance Improvement (QAPI) (a program to improve the processes for the delivery of health care and quality of life for the residents) program in place with policies and protocols describing how the facility will identify and correct its own quality deficiencies. This deficient practice had the potential to affect all residents in the facility. The facility's census was 33. The facility did not provide a policy in regards to the QAPI program. Review showed the facility did not have a QAPI plan that contained the necessary policies and protocols describing how they would identify and correct their quality deficiencies, track and measure performance, and establish goals and thresholds for performance measurement. [...]

Inspectors wroteBased on interview and record review, the facility failed to allow resident access to personal funds on an ongoing basis. This practice affected 24 residents with personal funds accounts out of a census of 33. Review of the facility's policy titled, Petty Cash, undated, showed: - Ensure accountability for use of petty cash funds; - The only employee permitted access to petty cash is the bookkeeper. In his/her absence, another designated employee shall be permitted access. During the resident council group meeting on 08/16/23 at 9:16 A.M., Residents #3, #4, and #25 said they did not have access to funds after Friday afternoon until the following Monday morning due to the business office was closed. During an interview on 08/18/23 at 8:30 A.M., Resident #3 said the Business Office Manager (BOM) did not work on the weekends. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) at least two days before the end of Medicare benefits and a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to the resident's representative in writing. This notification informs the beneficiary about potential non-coverage and the option to continue services with the beneficiary accepting financial liability for those services. This practice affected one resident (Resident #15) out of three sampled residents. The facility census was 33. Review of the facility's policy titled, Medicare Beneficiary Notices, undated, showed an advance written notice of non-coverage should be signed and dated by the beneficiary or their representative. 1. Review of Resident #15's NOMNC form showed: - The resident discharged from skilled services on 06/27/23; [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a significant change Minimum Data Set (MDS), a federally mandated assessment to be filled out by the facility staff, within 14 days of a resident admitted to hospice. This affected one resident (Resident #15) out of two sampled residents. The facility census was 33. The facility did not provide a policy in regards to completion of a significant change MDS upon admission to hospice. 1. Review of Resident #15's medical record showed the resident admitted to hospice on 7/7/23. Review of the resident's MDS's showed: - A quarterly MDS, dated [DATE], with no hospice services received; - No significant change MDS dated within 14 days of the admission to hospice services on 07/07/23; - The facility failed to complete a significant change MDS after the resident admitted to hospice. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement a baseline care plan (the minimum healthcare information necessary to properly care for a resident) upon admission with specific interventions for three residents (Residents #9, #34 and #189) out of seven sampled residents. The facility census was 33. Review of the facility's policy, titled, Baseline Care Plan/Summary, undated, showed: - A Baseline Care Plan for each resident will be developed within 48 hours of the resident's admission to the facility; - The Baseline Care Plan will be based on information available from the transferring provider as well as discussions with the resident/representative. 1. Review of Resident #9's medical record showed: - An admission date of 06/01/23; - No documentation of a baseline care plan with specified interventions. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to update and revise care plans with specific interventions tailored to meet individual needs for one resident (Resident #4) out of 12 sampled residents. The facility census was 33. Review of the facility's policy titled, Resident Smoking Policy, not dated, showed: - All residents must be in direct supervision while smoking per the above schedule; - All cigarettes and lighters will be stored at the nurse's station; - Department Managers are responsible for insuring that someone is assigned from their department at the designated smoking time. 1. Review of the Resident #4's medical record showed a Smoking Assessment, dated 05/05/23, the resident was a safe smoker. Review of the resident's care plan, revised on 08/15/23, showed: - The resident chose to smoke independently knowing he/she was at risk of injury or fire; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a physician's order for a Foley catheter (a flexible tube placed in the bladder to drain and collect urine) for one resident (Resident #189) out of three sampled residents. The facility census was 33. The facility did not provide a policy regarding physician orders. 1. Observations on 08/15/23 at 2:34 P.M., and 08/16/23 at 8:30 A.M., showed Resident #189 lay in bed with a Foley catheter in place with a drainage bag attached to the bed frame. Review of the resident's nursing notes showed: - Resident with a Foley catheter, intact and patent, dated 08/11/23; - Foley catheter draining dark amber urine, dated 08/12/23; - Foley catheter intact and draining cloudy amber urine, dated 08/13/23. Review of the resident's Physician Order Sheet (POS), dated August 2023, showed no order for a Foley catheter. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safety of a smoking resident (Resident #14) out of two sampled residents. The facility census was 33. Review of facility's policy titled, Resident Smoking Policy, not dated showed: - All residents must be in direct supervision while smoking per the smoking schedule; - The designated smoking area is located at the end of 200 Hall; - All cigarettes and lighters will be stored at the nurse's station. 1. Review of Resident #14's medical record showed: - admitted on [DATE]; - Diagnoses included chronic obstructive pulmonary disease (COPD) (a group of lung diseases that block air flow and make it difficult to breathe) and hypertension (high blood pressure); - A completed smoking assessment upon admission; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents diagnosed with dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) had a personalized plan of care to ensure appropriate services to promote the resident's highest level of functioning and psychosocial needs were provided for one resident (Residents #9) out of two sampled residents. The facility census was 33. The facility did not provide a policy in regards to dementia care. 1. Review of Resident #9's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 06/08/23, showed: - Able to understand others and to be understood; [...]

Inspectors wroteBased on observation, interview and record review the facility failed to properly monitor the refrigerator temperatures in which stored medications, including insulin (medication used to treat diabetes), were kept. This had the potential to affect all residents. The facility census was 33. Observation and record review on 08/17/23 at 2:47 p.m., of the Refrigerator Temperature Logs, dated 07/01/23 through 08/17/23, showed: - No documentation of the refrigerator temperatures for 07/03/23 - 07/05/23, and 07/07/23 - 07/31/23; - No documentation of the refrigerator temperatures for 08/01/23 - 08/16/23; - There were 43 missed opportunities out of 47 opportunities to record the refrigerator temperature on the Refrigerator Temperature Logs. During an interview on 8/18/23 at 10:27 A.M., the Administrator said he expected the refrigerator temperatures to be checked and recorded every day.

Inspectors wroteBased on interview and record review, the facility failed to maintain an Antibiotic Stewardship Program that included antibiotic use protocols and a system to monitor antibiotic use. This deficient practice had the potential to affect all residents in the facility. The facility census was 33. Review of the facility's policy titled, Antibiotic Stewardship, showed: - The core elements for antibiotic stewardship in this facility include: facility leadership commitment to safe and appropriate antibiotic use; track measures of antibiotic use in the facility; regular reporting on antibiotic use and resistance to relevant staff such as prescribing clinicians and nursing staff; - The antibiotic stewardship program protocols describe how the program will be implemented and antibiotic use will be monitored, consequently protocols must: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe environment for the residents and staff by not removing miscellaneous items on top of the light fixtures. The deficient practice had the potential to affect all residents and staff in the facility. The facility census was 33. Review of the facility's policy titled, Physical Environment, not dated, showed: - Purpose is to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public; - Maintain all mechanical, electrical, and patient care equipment in safe operating condition; - Did not address displaying decorative items on top of the overbed lighting. 1. Observation on 08/15/23 at 10:20 A.M., of room [ROOM NUMBER] showed: - A 2 foot (ft.) x 4 ft. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program to control the fly population in the facility. This deficient practice had the potential to affect all residents. The facility census was 33. Review of the facility's policy titled, Physical Environment, not dated, showed: - Purpose is to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public; - The facility must maintain an effective pest control program so that the facility is free of pests and rodents. 1. Observation on 08/15/23 showed: - At 11:07 A.M., two flies crawled on the unmade bed next to the window in room [ROOM NUMBER]; - At 11:32 A.M., a fly flew around the bedside table next to the resident in room [ROOM NUMBER]; - At 11:35 A.M., a resident sat at a dining room table and actively killed flies at the table. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the required annual competency of Dementia Care (care of a resident with an impaired ability to remember, think, or make decisions) to one Certified Nurse Aide (CNA) (CNA E) out of two sampled CNAs and had the potential to affect all residents diagnosed with dementia. The facility's census was 33. The facility did not provide a policy in regards to the required annual Dementia Care competencies. 1. Review of CNA E's in-service record showed: - A hire date of 03/25/22; - No documentaion of the annual Dementia Care training provided for March 2022 through March 2023. During an interview on 08/18/23 at 9:45 A.M., the Director of Nursing said he/she was new to his/her position and was still learning what all was required for the nursing staff. [...]

Inspectors wroteBased on observation and interview, the facility failed to notify residents of the availability and location of the most recent survey results in an accessible location to the residents. This practice affected one resident (Resident #4) out of 12 sampled residents and three residents (Resident #3, #25 and #31) outside the sample and had the potential to affect all residents and visitors. The facility's census was 33 . The facility did not provide a policy in regards to the availability and location of the facility's most recent survey results. Observations on 08/15/23 at 10:30 A.M., and on 08/16/23 9:00 A.M., showed the most recent survey results were not posted in an easily observable place, and could not be found posted anywhere in the facility. [...]