Aspire Senior Living Carthage

Inspectors wroteBased on interviews and record review, the facility failed to protect the rights of self-determination of all residents when the facility staff did not ensure one resident (Resident #1) received, or was offered, showers on a routine basis per his/her reasonable preference. The facility census was 116. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents had a clean and comfortable environment when the shower in the shower room had black substance in the corner of the shower stall. The facility census was 119. Review of the facility's policy titled, Cleaning Bathrooms, dated 01/30/24, showed the following:-The purpose is to ensure facility bathrooms are clean and sanitary;-The procedure is to spray shower walls and floor surface with bathroom cleaner. Spread and wipe around shower walls and faucet with clean, wet rag. Use hand-held shower hose to rinse shower. Be sure all hair is removed from drain plate. Wipe dry;-Use a clean mop, clean water, and floor cleaner to mop bathroom floor working from the farthest side of the bathroom to the doorway. Staff should make sure the mop is wrung out properly to prevent puddles of water on the floor. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide care per standards of practice when staff failed to obtain physician orders to monitor, flush, and obtain blood from an implanted vascular access port (small device placed under the skin, usually in the chest, to provide long term access to a vein) and failed to include the implanted vascular access port on the resident care plan for one resident (Resident # 1). The facility census was 111. Review of the facility policy titled admission Orders, undated, showed the following:-The physician must provide written and/or verbal orders for the resident's immediate care and needs;-The orders should allow facility staff to provide essential care to the resident consistent with the resident's mental and physical status on admission. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure colostomy (surgical procedure that brings one end of the large intestine out through the abdominal wall) site care was provided per standards of practice when staff failed to obtain physician orders for the routine colostomy care/changes, failed to routinely assess the colostomy site, failed to document resident removed of the colostomy bag, and failed to document care of the colostomy for one resident (Resident # 1). Staff also failed to routinely assess the colostomy site and failed to document monitoring colostomy self-care for one resident (Resident # 2). The facility census was 111. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care per standards of practice when staff failed to consistently assess and document complete, thorough weekly skin assessments and failed care plan related to skin for three residents (Resident #3, Resident #2, and Resident #4) and when staff applied treatment to skin conditions without physician's orders for two residents (Resident #3 and #4). A sample of six residents were reviewed in a facility with a census of 111. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure allegations of possible abuse were reported immediately to management and within two hours to the State Survey Agency (Department of Health and Senior Services - DHSS) when staff received allegations of possible abuse involving one resident (Resident #1) and failed to report the allegation in a timely fashion. The facility census was 110. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards of practice and in a manner to prevent possible contamination when the facility staff failed to air dry dishes before stacking; failed to wear hair restraints appropriately; failed to maintain a proper air gap to prevent possible back flow; failed to maintain the ice machine and scoop; and failed to maintain food contact surfaces and nonfood contact surfaces, including the stove/oven, in a manner that would prevent possible contamination of food. These concerns had the potential of affecting any of the residents. The facility census was 111. 1. Review of the 2022 Food Code, issued by the Food and Drug Administration (FDA), showed the following information: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed provide a sanitary environment in the kitchen when staff failed to ensure all areas in the kitchen were kept clean. This could have the potential to affect all of the residents. The facility had a census of 111. Review of the 2022 Food Code, issued by the FDA, showed the following information: -The objective of cleaning focuses on the need to remove organic matter from food contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted; -The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a risk/benefit review. document alternatives attempted prior to bed rail use, and failed to obtain informed consent prior to the use of bed side rails for six residents (Residents #266, #26, #53, #41 #28, and #59); failed to address and/or timely address the use of bed side rails in the residents' care plans for three residents (Resident # 266, #28, and #59); failed to conduct an initial safety gap check prior to side rail use for three residents (Residents #41, #28, and #59); and failed to ensure staff conducted periodic safety rechecks of all bed rails in use. The facility census was 111. Review of the facility policy titled Resident Beds and Bed Safety Rails Program, dated 10/28/19, showed the following: -The scope was to maintain beds and perform bed safety rails audits; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comfortable and homelike environment for one resident (Resident #52), whose room contained multiple areas of wall, door, and ceiling damage. A sample of 21 residents was reviewed. The facility census was 111. Review of a facility policy entitled Repair Requisition (TELs (electronic application) Work Order System), dated 07/06/15, showed the following: -Purpose was to assist in the prompt repair of equipment, or facility plant features, that may be broken or have failed; -TELs Work Order Requests are used as a communication tool and are not intended to be a permanent record of equipment service; -Requests for repairs to equipment, or the building, should be communicated via the TELs Work Order System to the maintenance department, using the TELs app on each computer. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide respiratory care per standards of practice when staff failed to obtain and document physician orders for the use of supplemental oxygen for one resident (Resident #53) of four sampled residents. The facility census was 111. Review of the facility's policy titled Advanced Care Procedures: Oxygen Administration, dated 12/08/05, showed the following: -Oxygen should be administered under the orders of the attending physician, except in the case of an emergency. In an emergency, oxygen may be administered without physician's order; however, the order should be obtained immediately after the crisis is under control; -Obtain physician's orders for the rate of flow and route of administration of oxygen (i.e., by tank, concentrator, nasal cannula, mask, etc.). 1. [...]

Inspectors wroteBased on observations,interviews, and record review, the facility failed to ensure food was properly stored, prepared, distributed, and served in accordance with professional standards for food service safety as required for 115 census residents who received meals from the facility kitchen. These failures had the potential to lead to food-borne illness among all facility residents. Review of the Dietary Service Manual, dated 08/10/18, showed the following: -Kitchens and dining areas should be kept clean, free from litter, and rubbish, and protected from rodents, roaches, flies, and other insects; -Utensils, counters, shelves, and equipment should be kept clean, maintained in good repair, and should be free from breaks, corrosion, open seams, cracks, and chipped areas; [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to keep one out of six medication carts secured; failed to remove expired calibration solution from one out of the two medication rooms; and failed to removed two expired covid tests. These failures had the potential for resident medications to be tampered with, glucometers to be calibrated inaccurately, and for expired covid tests and medications which may be less effective be used. The facility census was 115. 1. Review of the Storage and Expiration of Medication, Biological, Syringes, and Needles policy, with a revision date of 10/31/16, showed the facility should ensure that all medications and biologicals are securely stored in a locked cabinet/cart or a locked medication room that is inaccessible by residents or visitors. During observations on 10/25/23, from 11:09 A.M. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure each resident received an accurate Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) reflective of the resident's status at the time of the assessment for one resident (Resident #16) out of a total sample of 34 residents. The facility census was 115. 1. Review of the Centers for Medicare and Medicaid (CMS)'s RAI 3.0 Manual, revised October 2023, showed in the coding instructions for wandering that the frequency of the behavior during the seven day look back period should be coded. Review of the Resident's #16's admission Record, found in the Profile tab of the electronic medical record (EMR), showed the following: -admission date of 01/18/10; [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure a Level 1 Preadmission Screening and Resident Review (PASRR) was completed for one resident (Resident #15) of one sampled resident reviewed for PASARR failure to complete a Level 1 screen which prevents the completion of an in-depth evaluation (Level II PASRR) and possible identification of appropriate services. The facility census was 115. Review of the Preadmission Screening Resident Review policy, revised on 06/09, showed the following: -The process for PASRR included a Level I and/or Level II would be added to the admission checklist as one of the documents required prior to or at the time of admission; [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to develop a comprehensive care plan for one resident (Resident #21) out of a total sample of 32 residents when the resident had a physician order for oxygen use and the facility failed to develop a care plan related to oxygen usage. The facility census was 115. Review of the Nursing Management Manual Policy, effective 08/15/18, under the Quality of Life section with a Person Centered Care Plan policy title, showed the following: -The purpose of a person-centered plans of care was to care approaches and goals specific to the resident's needs; [...]

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure two residents (Residents #40 and #59) out of two residents observed out of a sample of 32 residents were positioned appropriately at the dining table to ensure the residents could access their food without difficulty and at a comfortable position. This had the potential for the residents to have nutritional issues and a negative dining experience. The facility census was 115. Review showed the facility did not provide a policy related to dining and positioning. 1. Review of Resident #40's facility provided quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff) with an Assessment Reference Date (ARD) of 09/15/23, showed the following: -admission date of 05/29/21; -Cognition was moderately impaired, made poor decisions, and supervision was required; [...]

Inspectors wroteBased on interview and record review, the facility failed to review and update the comprehensive facility assessment annually, in accordance with all applicable Federal requirements. Failure to review and update the comprehensive facility assessment annually could delay the services needed to care for the residents in day-to-day operations and in emergencies. This failure could affect all facility occupants. The facility census was 79. Record review of the facility's assessment policy, undated, showed the following: -It is the policy of this facility that it must conduct and document an individualized facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. -The facility assessment will be conducted at the facility level and may incorporate input from governing body/ownership. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a switch that would activate the resident call light system in four common-use restrooms. This deficient practice had the potential to affect all residents and visitors who used the restrooms and required staff assistance. The facility had a census of 79. 1. Observation on 3/13/20, beginning at 9:00 A.M., showed two unsecured common-use restroom doors, located in the therapy hall, in which residents could access. Staff attached the restroom door key to the outside of each door. Neither restroom had a call light activation switch. 2. Observation on 3/13/20, at 11:30 A.M., showed two unsecured common-use restroom doors, located in the main lobby, in which residents could access. Staff attached the restrooms door key to the outside of each door. Neither restroom had a call light activation switch. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to check the Nurse Aide (NA) registry prior to hire to ensure new employees did not have a Federal Indicator (a registry that indicated a list of individuals who had a previous incident involving abuse, neglect, or misappropriation of property that would prevent the employee from working in a certified long-term are facility) for one (Licensed Practical Nurse (LPN) A) out of five sampled employees, The facility census was 79. 1. Record review of LPN A's personnel file showed the following: -Hired on 6/4/19; -No documentation the facility completed the NA registry check prior to or upon hire for the employee. During an interview on 3/13/20 at 11:35 A.M., Financial Specialist Assistant B said the following: -LPN A previously worked at the facility from 8/29/17 to 9/1/17. Staff checked NA Registry at that time. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure all residents were free from significant medication errors when staff administered insulin (medication used to help control blood sugar levels) without priming the insulin pen, per standards of practice, prior to administration for one resident (Resident #22). The facility census was 79. Record review of the facility's policy, titled Medication Administration Procedures, Subcutaneous (just under the skin) Injection with Novolog Flexpen, dated 5/2012, showed the following: -Give the airshot before each injection: Small amounts of air may collect in the needle and insulin reservoir during normal use. To avoid injecting air and to ensure proper dosing follow the steps described below. -Hold the syringe with the needle pointing up and tap the syringe gently so any air bubbles collect in the top of the reservoir; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff appropriately documented the results of the yearly tuberculosis (TB) (an infectious disease that generally affects the lungs, but can also affect other parts of the body) skin test for two residents (Resident #9 and #22) and failed to complete the yearly TB signs and symptoms form for one resident (Resident #58) in a selected sample of 18 residents. The facility's census was 79. General requirements for TB testing for residents in Long Term Care Facilities, 19 CSR 20-20.100, reads as follows: -Long-term care facilities shall screen their residents for tuberculosis using the Mantoux method purified protein derivative (PPD) five tuberculin unit test. Each facility shall be responsible for ensuring all test results are completed and documentation is maintained for all residents; [...]