Aspire Senior Living Jonesburg

Inspectors wroteBased on observation, interview, and record review, facility staff failed to safely transfer one resident (Resident #3) when staff failed to utilize two staff members while using a mechanical lift, the mechanical lift tipped over, which resulted in left femoral fractures, right femur fractures, a bruise to the forehead, and a T12 compression fracture (occurs when the 12th thoracic vertebra) required hospitalization. Facility staff failed to utilize two staff for bed mobility for one dependent resident (Resident #1) which resulted in a femur fracture. Facility staff failed to utilize two staff in a manner to assure resident safety for one resident (Resident #2) out of three sampled residents. The facility census was 63.1. [...]

Inspectors wroteBased on interview and record review, facility staff failed to notify the physician after a change in condition for one resident (Resident #1) out of one sample residents when staff assisted the resident with positioning, heard a pop and the resident complained of pain. The facility census was 63.1. Review of the facility's Notification of Changes policy, dated 01/30/24, showed the facility must immediately inform the resident, consult with the resident's physician, and notify, consistent with his/her authority, the resident representative(s) when there is a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). 2. [...]

Inspectors wroteBased on interview and record review, facility staff failed to meet professional standards of practice when staff failed to complete weekly skin assessments for one resident (Resident #1) out of three sampled residents. The facility census was 62.1. Review of the facility's policy titled Skin Integrity, dated 01/30/24, showed the medical record will contain all documentation regarding assessment of skin. Review of the facility's policy titled Skin Observation, undated, showed a full body, or head to toe, skin observation will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter;The facility did not provide a policy for following physician's orders.2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 09/25/25, showed staff assessed the resident with moderate cognitive impairment. [...]

Inspectors wroteBased on interview and record review, facility staff failed to notify one resident's (Resident #1) out of one sampled resident representative in a timely manner when staff assessed the resident with an open area to the knee and bone protruding through the skin. The facility census was 59. The administrator was notified on 11/18/25 of Past Non-Compliance, which occurred on 10/06/25 when nursing staff failed to notify Resident #1's Power of Attorney (POA) of a change in condition to an old fracture to the right knee with new bone protrusion. Nursing staff completed in-service training on when and who to notify after a change in condition on 10/10/2025. 1. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to use standardized recipes to prepare foods for service to all residents and serve food in accordance with the nutritionally calculated menus. Facility staff failed to provide menus with the food items and portion sizes to be served for all diet types utilized by the facility and failed to record substitutions made to the menus. These failures have the potential to affect all residents. The facility census was 59. 1. Review of the facility's policy titled Food Service to Residents, dated 01/30/24, showed food will be prepared and served in a manner that meets the individual needs of the resident. Review of the facility's policy titled Menus, dated 01/30/24, showed the policy directed staff that the menus must: [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to store food in a manner to prevent potential contamination and outdated use and ensure the use of food in a first-in, first-out manner. Facility staff failed to ensure dishes were clean and air dried prior to stacking in storage to prevent the growth of foodborne pathogens. Facility staff failed to perform hand hygiene as often as necessary using approved techniques to prevent cross-contamination. Facility staff also failed to maintain kitchen surfaces and equipment clean and in good repair to prevent potential contamination. These failures have the potential to affect all residents. The facility census was 59. 1. Review of the facility's policy titled Storage of Food in Refrigeration, dated 01/30/24, showed: -Store raw meats on the bottom shelves to prevent contamination of other perishable items; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to provide a comfortable and homelike environment for residents, when staff failed to maintain resident rooms. Staff failed to clean and maintain wheelchairs for four residents (Resident #5, #6, #16, and #58) of 24 sampled residents. The facility census was 59. 1. Review of the facility policy titled Maintenance, dated 01/30/24, showed it is the job of all staff to identify areas of concern regarding the maintenance of the building. Preventive maintenance will occur throughout the year. Review of the facility policy titled Maintenance Work Request, dated 01/30/24, showed when a resident, staff member, or family member recognizes the need for maintenance services, a Maintenance Work Request form will be completed by a staff member. [...]

Inspectors wroteBased on interview and record review, facility staff failed to review and revise the care plan for three residents (Resident #6, #38 & #55) with diagnoses and/or activity preferences out of 24 sampled residents. The facility census was 59. 1. Review of the facility policy titled Comprehensive Care Plan, dated 01/30/24, showed each resident will have a person-centered comprehensive care plan developed and implemented to meet his/her preferences and goals and address the resident's nursing, medical, physical, mental, and psychosocial needs identified in the comprehensive assessment. The comprehensive care plan will be developed by the interdisciplinary team using the Minimum Data Set (MDS), a federally mandated assessment tool, to assess the resident's clinical condition as well as cognitive and functional status and the use of services. [...]

Inspectors wroteBased on interview and record review, facility staff failed to document the required neurological checks (an assessment completed to determine if the nervous system is impaired) and update the plan of care with interventions after falls for four residents (Resident #6, #21, #25 and #34) out of 24 sampled residents. Staff failed to update the fall risk assessment for three residents (Resident #21, #25, and #34) out of 24 sampled residents. The facility census was 59. 1. Review of the facility policy titled Fall Incident Reporting and Neurological Checks Policy, undated, showed the purpose is to ensure timely, accurate reporting and monitoring following any resident fall in order to promote safety, identify causes, prevent recurrence, and promptly detect and manage potential injuries, especially head trauma. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to use proper hand hygiene and provide perineal care in a manner to reduce the risk of infection for four residents (Residents #1, #5, #41 and #55) out of five sampled residents. The facility staff failed to implement appropriate infection control procedures to prevent the spread of communicable diseases when staff failed to screen four staff (Nurse Aide (NA) S, Registered Nurse (RN) P, Certified Medication Technician (CMT) Q and NA R) out of 8 staff sampled for tuberculosis (TB), a contagious, air-borne bacterial infection primarily affecting the lungs, in accordance with facility policy. The Facility census was 59.1. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to provide care and services in a dignified manner, when staff propelled one resident (Resident #55) of a sample of 24 residents, down the hall backwards in a mechanical chair and left one resident (Resident #6) of a sample of 24 residents, in the dayroom with clothes soiled with food debris. The facility census was 59.1. Review of the facility's policy titled, Protecting, Promoting and Ensuring Resident Rights-Facility Responsibility, undated, showed each resident has the right to a dignified existence. All staff will be advocates for resident rights. Review of the facility's policy titled, Resident Rights, undated, showed staff should ensure that resident rights are respected, protected, and promoted. Staff should inform residents of their rights and provide an environment in which they can be exercised. [...]

Inspectors wroteBased on interview and record review, facility staff failed to consistently document the code status as Do Not Resuscitate (DNR) or Full Code - Cardiopulmonary resuscitation ((CPR) an emergency procedure that combines chest compressions and rescue breathing to restart a person's breathing and heartbeat) on the face sheet, and/or Physician Order Sheet (POS) for five residents (Resident #20, #25, #34, #42 and #53) out of 24 sampled residents. The facility census was 59.1. Review of the facility policy titled Basic Life Support/CPR, dated [DATE], showed the purpose is to ensure this facility is able to, and does provide, emergency basic life support when needed, including CPR, to any resident requiring such care prior to the arrival of emergency medical personnel in accordance with related physician orders, such as DNR and the resident's advance directives. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to obtain signed consent for bed rail use and failed to assess three residents (Resident #2, #5 and #15) out of four sampled, for bed rail use. The facility census was 59. 1. Review of the facility's policy titled Bed Rail, dated 01/30/2024, showed bed rails are adjustable metal or rigid plastic bars that attached to the bed. Examples of bed rails include grab bars, assist bars, side rails, and safety rails. Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. The Facility should maintain evidence that is has provided sufficient information so that the resident or resident representative could make an informed decision. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to complete entrapment assessments and regular inspections of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for four residents (Residents #2, #3, #5, and #15) out of four sampled residents. The facility census was 59.1. Review of the facility's policy titled Bed Rail, dated 01/30/24, showed assess the resident for risk of entrapment from bed rails prior to installation. Ensure the bed's dimensions are appropriate for the resident's size and weight. Inspect and regularly check the mattress and bed rails for areas of possible entrapment. Check bed rails regularly to make sure they are still installed correctly as rails may shift or loosen over time. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to complete the required nurse staffing information to include the facility census. The facility census was 59.1. Review of the facility's policy titled Nurse Staffing Information, dated 01/30/24, showed the facility must post resident census daily at the beginning of each shift in a clear and readable format.2. Review of facility's August daily nurse staffing sheets showed the sheets did not contain a facility census on 08/07, 08/08, 08/12- 08/15, 08/18, 08/19, and 08/25- 08/28/25. 3. Observation on 08/25/25 at 11:49 A.M., showed the facility nurse staff posting located by the nurses' station did not contain a facility census. Observation on 08/26/25 at 10:13 A.M., showed the facility nurse staff posting located by the nurses' station did not contain a facility census. [...]

Inspectors wroteBased on record review and interview, facility staff failed to report to the Department of Health and Senior Services (DHSS) within the two-hour required timeframe a resident to resident altercation between two residents (Resident #1, and Resident #2) when Resident #1 slapped Resident #2. The facility census was 56. 1. Review of the facility's abuse, neglect, exploitation or mistreatment policy, dated 1/30/24, showed the purpose of the policy is to ensure all alleged violations related to mistreatment, exploitation, neglect, or abuse are thoroughly investigated and reported to the proper authorities within the required time frames. [...]

Inspectors wroteBased on record review and interview, facility staff failed to ensure one resident (Resident #1) remained free from verbal and physical abuse when Certified Nursing Assistant (CNA A) threatened Resident #1 with rough treatment. The facility census was 60. The administrator was notified on 12/24/24 of past Non-Compliance which occurred on 12/24/24. On 12/24/24, staff notified the administrator they witnessed CNA A telling Resident #1 he/she would manhandle the resident if the resident did not cooperate with care. Staff immediately suspended CNA A, assessed the resident for injuries, and notified the required parties and agencies. The administrator terminated CNA A on 12/26/24. The administrator in-serviced all staff, on abuse and neglect policies and procedures by 12/30/24. 1. [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide an appropriate emergency discharge notice for one resident (Resident #1) and failed to allow Resident #1 to return to the facility when the resident was ready for discharge from the hospital. The facility census was 62. 1. Review of the facility's Transfer and Discharge policy, undated, showed staff were directed to: -Ensure resident rights are protected when the facility can no longer provide care or services needed; -The facility must notify the resident at least thirty days prior to the anticipated transfer; -A transfer or discharge will not be done except when the safety of individuals in the facility is endangered, due to the clinical or behavioral status of the resident, and as documented/confirmed by a physician; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to provide a comfortable and homelike environment for residents, when staff failed to maintain walls, floors, lighting, and sink countertops in good repair. The facility census was 60. 1. Review of the facility's Physical Environment policy, undated, showed: -The facility will provide a safe, functional, sanitary and comfortable environment for residents, staff and the public; -The facility must be designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel and the public; -Resident rooms must be designed and equipped for adequate nursing care, comfort, and privacy of residents; -Maintain all mechanical, electrical, and patient care equipment in safe operating condition; [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide written information to the resident and/or the resident's representative of the bed hold policy for three residents (Resident #27, #50, and #163) of three sampled residents who discharged to the hospital. The facility census was 60. 1. Review of the facility's Bed Hold policy, undated, showed the following: -The facility will notify all residents, and/or their representative of the bed hold policy guidelines upon admission to the facility, at the time of transfer to the hospital or leave and at the time of non-covered therapeutic leave; -If the resident or representative wants to hold the bed, a signed authorization of the bed hold selection notice must b e obtained with each physician approved hospitalization; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to develop a comprehensive person-centered care plan to meet the resident's medical, nursing, mental and psychosocial needs for three residents (Resident #41, #44, and #164) out of ten sampled residents. The facility census was 60. 1. Review of the facility's Care Plan Comprehensive policy, dated March 2015, showed: -The comprehensive care plan will be based on a thorough assessment that includes, but is not limited to, the Minimum Data Set (MDS), a federally mandated assessment tool; -Assessment of each resident is ongoing process and the care plan will be revised as changes occur in the resident's condition; -The interdisciplinary team is responsible for the periodic review and updating of care plans when a significant change has occurred, at least quarterly, and when changes occur that impact the resident's care; [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide the services of a Registered Nurse (RN) for at least eight (8) consecutive hours per day, seven days a week. The facility census was 60. 1. Review of the Facility Assessment, reviewed July 2024, showed the facility to have an RN at least 8 hours per day, seven days a week. Review of the facility's Nurse Staffing, dated 08/01/24 through 08/22/24, showed staff did not provide an RN eight hours a day on 8/3/24, 8/4/24, and 8/17/24. During an interview on 08/23/24 at 8:38 A.M., RN K said there are times when there is not an RN in the building and has been times that the only other RN aside from him/her was the Director of Nursing (DON). He/She said the DON tries to keep RN coverage on duty but one is not always available. RN K said he/she fills in when he/she can on the weekends. During an interview on 08/23/24 at 9:26 A. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to destroy medications in a timely manner for seven residents (Resident #1, #6, #20, #21, #23, #25, #33, and #37). Staff failed to discard expired medications from one out of two sampled medication carts. Failed to ensure medications were stored in a safe and effective manner, by not ensuring medications were properly labeled and contained in their original package until time of administration on two of two sampled medication carts. The facility census was 60. 1. Review of the facility's Medication Storage policy, dated March 2015, showed: -Medications must be stored in the container in which they were received; -No discontinued, outdated, or deteriorated drugs or biologicals may be retained for use. All such drugs must be returned to the issuing pharmacy or destroyed in accordance with established guidelines. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. This failure has the potential to affect all residents. The facility census was 60. 1. Review of the facility's Dietary Supervisor (DS) position description, undated, showed the minimum requirements for the position included Certified Dietary Manager Certification (CDM) or equivalent credential required. During an interview on 08/20/24 at 11:03 A.M., the DS said he/she had been the DS for about three years. The DS said he/she started the CDM course a couple of years ago, but never finished. The DS said he/she had not completed other dietary management training. [...]

Inspectors wroteBased on observations, interviews and record review, facility staff failed to close the computer screens from view which showed resident information when left unattended for two (Resident #44 and #46) out of five sampled residents and on two medication carts. The facility census was 60. 1. Review of the facility's Protecting, Promoting and Ensuring Resident Rights policy, dated 1/30/24, showed the resident has the right to personal privacy and secure confidential personal and medical records. 2. Observation on 08/21/24 at 2:33 P.M., showed Registered Nurse (RN) J entered Resident #44's room and did not minimize or lock the compter screen on the treatment cart. Observation showed the residents medical information displayed. Observation on 08/21/24 at 2:51 P.M., showed RN J entered Resident #46's room. and did not minimize or lock the compter screen on the treatment cart. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to post the required nurse staffing information in an manor easily accessible for residents and visitors, and failed to include the required data in the posting. The facility census was 60. 1. Review of the facility's Nurse Staffing Information policy, undated, showed: -The facility must post the following information daily: facility name, current date, the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Registered Nurse (RN), Licensed Practical Nurses (LPN) and Certified Nurse Aides (CNA), and the resident census; -The facility must post the nurse staffing data as specified above daily at the beginning of each shift; -Must be posted in a prominent place readily accessible to residents and visitors. 2. [...]

Inspectors wroteBased on observation and interview, facility staff failed to use appropriate infection control procedures to prevent or reduce the risk of spreading bacteria, when staff failed to wash or sanitize their hands in between glove changes when providing wound care for four residents (Resident #1, #2, #3, and #4) of four sample residents. The facility census was 62. 1. Review of the facility's policy titled, Wound Care and Treatment, dated 03/2015, showed staff were directed to do the following: -Hand washing must be done as outlined in the guidelines; -Put gloves on; -Remove the soiled dressing and place in the trash bag; -Remove the gloves and discard in the bag; -Wash your hands and put on clean gloves; -Clean the wound according to the order; -Remove gloves, place in trash bag, and put on a clean pair of gloves; -Apply clean dressing as ordered; -Wash your hands. 2. [...]

Inspectors wroteBased on record review and interview, the facility failed to establish and maintain a process to follow generally accepted accounting principles to reconcile the Resident Trust Fund Account monthly. The facility census was 59. 1. Review of the facility's policies showed the facility staff did not provide a policy for reconciling the resident trust fund. Review of reconciled resident trust bank statement balances and resident trust fund balance reports for the period from July 2022 through June 2023 showed staff did not reconcile the accounts at the end of each month. Further review showed reconciled bank statement and resident trust balances as follows: -July 22 Reconciled bank balance was $65,746.10, Trust balance was $65,218.30; -August 22 Reconciled bank balance was $69,661.05, Trust balance was $68,948.20; [...]

Inspectors wroteBased on interview and record review the facility staff failed to document residents' code status consistently, Do Not Resuscitate (DNR) or Full Code (Resuscitate refers to cardiopulmonary resuscitation-CPR) for three residents (Resident #23, #31, and #48). The facility census was 59. 1. Review of the facility's Advance Directive Policy, dated [DATE], showed: -Upon admission of a resident, the social services designee will inquire of the resident, and/or his/her family members, about the existence of any written advanced directives; -Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record under the advanced directive tab. 2. Review of Resident #23's Face Sheet in their Electronic Medical Record (EMR) showed staff documented the resident as full code status. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to ensure residents had a DA-124 Level I screen (used to evaluate for the presence of psychiatric conditions to determine if a preadmission screening/resident review (PASARR) Level II screen is required) completed as required, for three residents (Residents #21, #48, and #52). The census was 59. 1. Review of the facility's policies showed the facility did not provide a policy for PASARR screening. 2. Review of Resident #21's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/15/23, showed the following: -Date of admission 6/1/21; -No screening information regarding PASARR, Level II PASARR, or conditions related to serious mental illness/intellectual disabilities/related conditions; [...]

Inspectors wroteBased on staff interview and record review, facility staff failed to meet professional standards of care when nursing staff did not count scheduled narcotics at change of shift when the medication cart changed from one staff member to another. The facility census was 59. 1. Review of the facility's Scheduled Medications policy, dated March 2015, showed: -Scheduled medications will have disposition records that are in a binder on the medication cart or area instructed by the Director of Nursing (DON); -All schedule II, III, IV, V medications must be counted (comparing number of pills to disposition record) at every change of shift by two Certified Medication Technician (CMT)s, or one CMT and one licensed nursing staff; Both personnel must sign verification of correct count for Schedule II, III, IV and V medications; [...]

Inspectors wroteBased on observation, interview, and record review facility staff failed to assist seven out of fifteen sampled dependent residents (Resident #5, #10, #21, #28, #41, #56 and #57) with grooming and bathing as needed. The facility census was 59. 1. Review of the facility's Activities of Daily Living (ADL) policy, dated March, 2015, showed the policy did not give staff direction for bathing and grooming. 2. Review of Resident #5's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 6/17/23 , showed facility staff assessed the resident as: -Cognitively intact; -Totally dependent on two plus persons for transfers; -Totally dependent on two plus persons for toilet use: -Required physical help of one person for bathing. [...]

Inspectors wroteBased on observation, resident and staff interview and record review, facility staff failed to ensure the resident environment remained free of accident hazards when facility staff failed to ensure electronic cigarettes were kept secure for one resident (Resident #10), failed to ensure hazardous chemicals were stored in a safe manner not accessible to residents, and failed to ensure one resident (Resident #23) took all medications prior to leaving the resident's room, leaving two potassium pills on the resident's bedside table. The facility census was 59. Review of the facility's policy Resident Rules and Regulations, undated, showed the following: - For safety reasons, the resident and any visitor to this facility is hereby advised not to smoke cigars, cigarettes, and vapes except under supervision and/or in designated smoking areas. [...]

Inspectors wroteBased on observation, interview, and record review facility staff failed to store and label medications in safe and effective manner in one of one medication storage rooms, and one of two medication storage carts. The facility census was 59. 1. Review of the facility's Medications, Storage Of Policy, dated March, 2015, showed staff were directed as follows: -No discontinued, outdated, or deteriorated drugs or biologicals may be retained for use. All such drugs must be returned to the issuing Pharmacy or destroyed in accordance with established guidelines; -Medications must be stored in the container they were received in. 2. Observation on 7/13/23 at 8:40 A.M., showed the medication storage room contained one Medline lubricating jelly box of 144 packets with an expiration date of June 2023. Observation on 7/13/23 at 9:00 A.M., showed the 500 hall medication cart contained the following: [...]

Inspectors wroteBased on interview and record review, the facility staff failed to maintain and follow current guidance and procedures for immunizations of residents against pneumococcal pneumonia (infection caused by bacteria) in accordance with national standards of practice and failed to offer, administer, and document the administration or refusal of the pneumococcal immunization for two of eight residents (Residents #3 and #41) sampled. The facility census was 59. 1. Review of the facility's policies showed staff did not provide a resident immunization policy. Review of the U.S. Department of Health and Human Services Centers for Disease Control and Prevention (CDC), pneumococcal and influenza vaccine timing for adults, dated 2023, showed the following: -Four types of pneumonia vaccines are acceptable for adults 65 years or older. PCV13: 13-valent pneumococcal conjugate vaccine (Prevnar13), PCV15: [...]

Inspectors wroteBased on record review and interview, facility staff failed to implement policies and procedures for reporting when staff failed to notify local law enforcement agency for a potential theft of pain medication and failed to notify the State Survey agency for a resident to resident altercation after Resident #48 punched Resident #46 in the shoulder. The facility census was 59. 1. Review of the facility's Abuse policy, dated November 2017, showed: -The nursing home Administrator or designee will report abuse to the state agency per State and Federal requirements; -The facility will ensure that any reasonable suspicion of crimes committed against a resident of this facility will be reported to the appropriate Law Enforcement Agency as established by section 6703(b)(3) of the Patient Protection and Affordable Care Act of 2010. [...]

Inspectors wroteBased on observation, interviews and record review facility staff failed to ensure one resident (Resident #3) who received tube feeding (supplies liquid nutrition) through a gastrostomy tube (G-tube, a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) received the appropriate treatment and services. The census was 59. 1. Review of the facility's Enteral Nutritional Therapy (Tube Feeding) policy, dated March 2015 showed staff are instructed to check the pump flow rate every shift and clear pump at the end of shift to document volume infused. Review of Resident #3's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 4/06/23, showed facility staff assessed the resident as: -Severe cognitive impairment; -Totally dependent for feeding and hygiene; [...]

Inspectors wroteBased on observations, interviews and record review, the facility staff failed to review, revise and develop individualized interventions for one resident (Resident #48) who had behaviors and failed to provide the required Nurse Aide dementia training in the past 12 months. The facility census was 59. 1. Review of the facility assessment dated [DATE], showed: -22 Residents have behavioral health needs; -All staff will be trained on hire and annually regarding care and management of persons with dementia; -Certified Nurse Aides will be trained on hire and annually regarding dementia management training. Review of the facility's Census and Conditions dated 7/11/23 showed: -29 residents with dementia or Alzheimer's Disease; -22 residents with behavioral healthcare needs. Review of the facility's Care Plan Comprehensive policy, dated March 2015 showed: [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to post the telephone number for the Department of Health and Senior Services (DHSS) Adult Abuse and Neglect Hotline (used to report allegations of abuse and neglect) in a form and manner accessible to residents and visitors, and failed to post the name, address and phone number for the Long-Term Care Ombudsman and resident rights on the secured unit. The facility census was 59. 1. Review of the facility's policies showed the facility did not provide a policy for the required postings. Observations from 7/11/23 at 10:00 A.M. [...]

Inspectors wroteBased on interview and record review, facility staff failed to review and update their Infection Prevention and Control Program (IPCP) on an annual basis. The facility census was 59. Review of the facility's Infection Prevention and Control Program binder, undated, showed it contained a blank cover page to be used to document annual reviews. Review of the facility's Change of Ownership documentation, showed the current facility ownership was effective 6/01/21. During an interview on 7/14/23 at 11:55 A.M., the Director of Nursing (DON)/ Infection Preventionist (IP) said the facility's Infection Prevention and Control policies were not reviewed or updated annually. The DON/IP said the new owners provided the manual but he/she hasn't done anything with it. He/She said the policies are supposed to be reviewed every year and he/she did not know why they were not.

Inspectors wroteBased on interview and record review, facility staff failed to provide resident council with a written response to grievances. The facility census was 59. 1. Review of the facility's policy Section 504 Grievance Guidelines showed the policy did not contain direction for staff concerning written responses to a grievance. Review of the resident council minutes for the months of May, June, and July 2023 showed staff did not document they provided a written response to resident council grievances. 2. During an interview on 7/12/23 at 2:40 P.M., resident council members said it takes a long time to hear about concerns brought to the facility's attention from council meeting and they do not get a written response about what will be done from facility staff. [...]