Aspire Senior Living Joplin

Inspectors wroteBased on interview, and record review, the facility failed to provide care per standards of practice when staff failed to complete ordered daily weights, failed to notify physician as ordered regarding excess weight gain, failed to document and monitor the resident's fluid restriction and intake, and failed to care plan new intervention for one resident (Resident #1) with a diagnosis of congestive heart failure (CHF - impaired heart function) contributing to the resident's hospitalization with severe hyponatremia (low sodium), hypervolemia (fluid overload), abdominal distention, and lower extremity edema. The facility census was 111. [...]

Inspectors wroteBased on interview and record review, the facility failed to establish and maintain a complete infection control program when staff failed to have processes in place to ensure all residents were screened for tuberculosis (TB - a serious illness that mainly affects the lungs and can be spread when a person with the illness coughs, sneezes or sings) when staff failed to complete a two-step test TB test for three residents (Resident #1, #3, and #4). The facility census was 111. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all residents were treated with dignity and respect, when staff did not assist one resident (Resident #4) to leave the dining room to have a soiled brief changed before mealtime. The facility census was 111. Review of a facility policy titled Resident Rights, dated January 2024, showed the following:-The purpose of the policy is to ensure resident rights are protected, respected, and promoted;-The facility will treat each resident with dignity and care for each resident in a manner and environment that promotes quality of life;-The resident has the right to live in the facility and receive services with reasonable accommodation of needs and preferences. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents only self-administered medication after it had been determined to be clinically appropriate when one resident (Resident #2) self-administered insulin injections independently without an assessment to determine competency or a physician order to allow for self-administration and failed to include self-administration of medication on the resident's care plan. The facility census was 111. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure a resident's wishes regarding a Do Not Resuscitate (DNR- an order signed by a physician that instructs healthcare providers not to perform cardio-pulmonary resuscitation (CPR - an emergency procedure that is performed when a person's heartbeat or breathing has stopped) if a resident's breathing or heart stops) order was honored when staff performed CPR for one resident (Resident #1). The facility census was 111. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services to meet the needs of each resident when a nurse reinitiated an order for Naltrexone (medication used to treat alcohol and opioid disorders) without a physician order for one resident (Resident # 5). The facility census was 111. Review of the facility policy titled Medication Administration, dated October 2025, showed medications are administered by licensed nurses, or other staff legally authorized to do so, as ordered by a physician and in accordance with professional standards of practice. 1. Review of Resident #5's face sheet (a document that gives a resident's information at a quick glance) showed the following:-admission date of 04/22/26;-Diagnoses included alcohol abuse. [...]

Inspectors wroteBased on record review and interview, the facility staff failed to ensure all residents were free of significant medication errors when staff failed to administer insulin for two residents (Resident #1 and #6) per physician order. The facility census was 111. Review of a facility policy titled Medication Administration, dated October 2025, showed the following:-Medications are administered by licensed nurses, or other staff legally authorized to do so, as ordered by a physician and in accordance with professional standards of practice;-Obtain and record vital signs and hold medication when vital signs are outside of the prescribed physician standards;-Sign the Medication Administration Record (MAR) after medication administration;-Report and document any adverse side effects or refusals. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure nurse aides (NA) were certified within the required time frame when four NAs (NA A, NA B, NA C, and NA D) continue to work with residents beyond four months without being certified. The facility census was 106. Review of the facility policy titled, Policy, Hiring of Non-Certified Nurse Aides(Missouri), undated, showed the following:-To establish guidelines for recruitment, hiring, training, supervision, and certification of individuals who are not yet certified Nurse Aides (CNAs) but employed as nurse aides and trains at the facility;-The facility may hire individuals who are not currently certified as CNAs to work as nurse aides trainees, provided they meet the state and federal requirements. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to have procedures in place to ensure the accurate dispensing and documentation of medication administration when staff left medication in a resident's room unsupervised for one resident (Resident #1) and when six medication cups with medication in them were left not administered in the medication cart labeled with room numbers for four residents (Resident #2, #3, #4, and #5) or unlabeled. The census was 106. Review of the facility's policy titled, Medication Self-Administration, dated 01/30/24, showed the following:-The purpose is to establish uniform guidelines concerning resident self-administration of medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care per standards of practice when staff failed to document assessment, monitoring, and physician notification of a fall with injury for one resident (Resident #1) resulting in staff on following shifts not being aware of the need of fall follow-up monitoring. The facility census was 110. Review of the facility's policy, Fall Prevention Program, dated 10/01/25, showed the following: -A ''fall refers to unintentional change in position coming to rest on the ground, floor or onto the next lower surface (e.g., onto a bed, chair, or bedside mat) or the result of an overwhelming external force (e.g., a resident pushes another resident). [...]

Inspectors wroteBased on interview and record review, the facility failed to have a process in place that established receipt and disposition of all controlled drugs when staff failed to document medications reconciliation upon discharge for one resident (Resident #1) resulting in a card of 30 Percocet (oxycodone-acetaminophen - a brand-name prescription pain medication containing a combination of two drugs: the opioid oxycodone and the non-opioid pain reliever acetaminophen) 5-325 milligrams (mg) for one previously discharged resident (Resident #2) being sent home with the resident (Resident #1). Three residents were sampled in a facility with a census of 112. On 10/14/25, the Administrator became aware of the noncompliance that occurred on 10/10/25 related to medication being sent home with the wrong resident. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure six nurse aides (Nurse Aide (NA) A, NA AA, NA V, NA W, NA X, NA Y, NA Z) of sixteen sampled NAs, completed a certified nurse aide (CNA) training program within four months of employment in the facility as a nurse aide. The facility census was 105. Review showed the facility did not provide a policy regarding nurse aide certification or training. Review of the facility provided list of current NA staff showed sixteen staff on the list. Six NA staff had been employed greater than 120 days. 1. Review of NA AA's personnel file showed the following: -Date of hire of 10/02/24 (seven months and eighteen days since date of hire); -Staff did not have documentation NA AA had completed the nurse aide training program. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep food safe from potential contamination at all times when staff failed to air dry dishes, failed to ensure the ice machine had a proper air gap, and failed to keep kitchen surfaces clean and free of food debris. The facility census was 105. 1. Review of the Food and Drug Administration (FDA) 2022 Food Code showed the Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Review of the facility policy titled Cleaning of Miscellaneous Equipment and Utensils, dated 09/03/19, showed dishes were to be allowed to air dry. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the facility's quarterly Quality Assurance Performance Improvement (QAPI) Committee meetings occurred at least quarterly and included the required staff. The facility census was 105. Review of the facility policy entitled Quality Assurance/QAPI, dated 11/28/19, showed the following: -The program monitors data, analyzes and improves its performance to improve resident outcomes. It recognizes that value in healthcare is the appropriate balance between good measures, excellent care, services and cost; -QAPI Committee will meet quarterly and the facility QAPI team will meet at a minimum monthly. Performance Improvement Project (PIP) committees will meet weekly and report to QAPI Committee concerns. At a minimum, one PIP will be charted per year; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote and facilitate the right of self-determination for every resident when staff failed to honor reasonable shower preferences for four residents (Resident #76, #92, #29, and #74) . The facility census was 105. Review of the facility's policy titled Hygiene and Grooming, from the Nursing Guidelines Manual, dated October 2010, showed the following information: -Good hygiene and grooming help prevent the spread of infection and promote the resident's feelings of self-worth and dignity; -Services may be provided on a varying schedule when a physician's order or physician documentation of a medical contraindication exists or when the resident needs services more frequently; -Resident preferences for time of day, type of bath, and frequency of bath should be honored to the extent possible; [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide a comfortable and homelike environment by failing to ensure the facility was in good repair, when staff failed to maintain a window screen for two residents (Resident #76 & #90), when staff failed to repair wall damage in one resident's (Resident #5) room, and when staff failed to maintain a clean shower on 200 hall. The facility census was 105. Review showed the facility did not provide a policy related to environment repairs. 1. Review of Resident #76's face sheet (a brief information sheet about the resident) showed an admission date of 06/24/23. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 03/26/25, showed the resident had moderate cognitive impairment. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure that staff notified the resident and/or the resident's representative in writing of a transfer to a hospital and failed to provide the bed hold policy at the time of transfer for six residents (Residents #41, #61, #78, #1, #306, and #25). The facility census was 105. Review of the facility's policy entitled Transfer, Discharge and Therapeutic Leaves (including Against Medical Advice (AMA)), dated 06/26/19, showed the following: -The resident has the right to refuse involuntary transfer out of or discharge from the facility under certain circumstances; -Transfer meant the moving of a resident from the facility to another legally responsible institutional setting. Discharge meant the moving of a resident to a non-institutional setting when the releasing facility ceases to be responsible for the resident; [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure three residents (Residents #53, #92, and #25) and/or their representative were invited to participate in the resident's quarterly care plan meeting. The facility census was 105. Review of facility policy titled Person Centered Care Plans, dated August 2018, showed the following: -Person centered plans of care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals of the resident; -The interdisciplinary plan of care committee may consist of nursing personnel having knowledge of the resident; Activities Director; Social Services Director; Dietary Manager/Registered Dietician or other members of Food & Nutrition Service; licensed therapists; attending physician; the resident; the resident family members and/or other representatives; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who were unable to carry out their own activities of daily living (ADLs) received the necessary services to maintain grooming and personal hygiene when staff did not perform or address toenail care for three residents (Residents #84, #10, and #64) of eight residents reviewed for nail care. The facility census was 105. Review of the facility's policy entitled Hygiene and Grooming, dated 10/01/10, showed the following: -Good hygiene and grooming help prevent the spread of infection and promote the resident's feelings of self-worth and dignity; -Guidelines for provision of hygiene and grooming services include shower, tub or complete bed bath, as needed; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an environment as free from possible accident hazards when staff failed to complete an assessment for, failed to monitor, and failed to care plan smokeless tobacco use for one resident (Resident #76). The facility census was 105. Review showed the facility did not provide a smokeless tobacco policy. 1. Review of Resident #76's face sheet (a brief information sheet about the resident) showed the following information: -admission date of 07/01/19; -Diagnosis included hemiplegia (paralysis on one side of the body) and hemiparalysis (weakness on one side of the body) following cerebral infarction (stroke, a condition where blood flow to the brain is interrupted, causing brain tissue to die) affecting left non-dominant side, memory deficit following cerebral infarction, anxiety disorder, and nicotine dependence. [...]

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, when staff did not obtain clarified orders for the use of supplemental oxygen for three residents (Residents #34, #65, and #41). The facility census was 105. Review of the facility's policy entitled Oxygen Administration, dated date, showed the following: -Purpose was to administer high purity oxygen for the treatment of certain diseases or conditions; -Oxygen should be administered under orders of the attending physician, except in the case of a 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; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have sufficient staff to meet the needs of the residents resulting in staff failing to answer call lights in a timely fashion for three residents (Resident #14, #39, and #61). The facility census was 105. Review showed the facility did not provide a policy related to call light response. 1. Observations on 05/14/25, at 8:23 P.M., showed the following: -Two call lights alarming on the 100 hall and Resident #14, Resident #39, and Resident #61 call lights alarming on the 500 hall; -Resident #41 yelling out on the 500 hall; -Resident #31 yelling for staff to help Resident #41 on the 500 hall; -Registered Nurse (RN) JJ passed medications to Resident #50 on 500 hall; -At 8:27 P.M., RN JJ entered Resident #41 room gave resident reassurance; -At 8:32 P.M., Resident #41 continued crying out; [...]

Inspectors wrote5. Review of the facility policy entitled Tuberculosis Screening, dated 11/14/16, showed the following: -Purpose was to prevent the spread of tuberculosis through early detection of the disease in residents/guests and employees; -Upon admission, residents should receive the PPD (purified protein derivative) two-step screening. If screening was done by the transferring hospital, it must have occurred within 30 days prior to nursing home admission; -Any resident with positive active TB, or suspicious symptoms, should be discharged to a hospital. The county health department should be notified within twenty-four hours; -Method one includes apply first test; read results in 7 days, and if result is negative (0-9 millimeter (mm) induration) apply second test the same day. Read results in 72 hours and use the second test as the baseline. -Method two includes -apply first test; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents were treated in a dignified manner when staff failed to remove two hospital bracelets from one resident's wrist (Resident #306) until 12 days after discharging from the hospital. The facility census was 105. Review of the facility policy titled Federal Rights of Residents/Guests, dated 11/28/16, showed the following: -The resident has a right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the facility; -The resident has the right to exercise his/her rights as a resident of the facility and as a citizen or resident of the United States; -The resident has a right to be treated with respect and dignity; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents' drug regimes were free from unnecessary drugs when staff failed to specify a diagnosis for use of a psychotropic medication for one resident (Resident #37). A sample of eight residents was reviewed in a facility with a census of 105. Review of the facility's policy titled, Psychotropic Medication Use, dated 12/01/02, showed the following: -Psychotropic drug is any medication that affects brain activities associated with mental processes and behavior; -All medications used to treat behaviors must have a clinical indication. 1 Review of Resident 37#'s face sheet (resident's information at a quick glance) showed the following: -admission date of 08/26/24; [...]

Inspectors wroteBased on interview and record review, the facility failed to follow appropriate discharge procedures when staff failed to complete discharge and/or transfer documentation in the medical record for one resident (Resident #14). The census was 105. Review of the facility's policy entitled Transfer, Discharge and Therapeutic Leaves (including Against Medical Advice (AMA), dated 06/26/19, showed the following: -The resident had the right to refuse involuntary transfer out of or discharge from the facility under certain circumstances; -Transfer meant the moving of a resident from the facility to another legally responsible institutional setting. Discharge meant the moving of a resident to a non-institutional setting when the releasing facility ceases to be responsible for the resident; [...]

Inspectors wroteBased on record review and interviews, the facility failed to refer a Pre-admission Screening and Resident Review (PASARR) resident who had a negative Level I Preadmission Screen, who was later identified with a new mental disorder diagnosis, to the appropriate state designated authority for a Level II PASARR evaluation and determination for one resident (Resident #25) out of 8 sampled residents. The facility census was 105. Review showed the facility's policy titled Preadmission Screening Resident Review, revised on 06/2009, showed the following: -Preadmission screening of nursing home patients to establish a Level I Determination is a federal requirement; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in accordance with professional standards when staff failed to notify the physician and family of frequent refusal of medications for one resident (Resident #40) for review of medication regimen and failed to complete accu-checks (blood glucose level checks) as ordered when one resident (Resident #25). The facility census was 105. 1. Review of the facility titled General Dose Preparation and Medication Administration, dated January 2013, showed the following: -Facility staff should comply with facility policy, applicable law, and the State Operations Manual when administering medications; -After medication administration, facility staff should document necessary medication administration information. [...]

Inspectors wroteBased on observation, record review, and interview the facility failed to provide pharmaceutical services to meet the needs of each resident when staff failed to obtain and administer eye drop medications as ordered for one resident (Resident #1) Review of the facility policy titled Medication Shortages / Unavailable Medications, dated January 2013, showed the following: -This policy sets forth procedures relating to medication shortages and unavailable medications; -Upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from pharmacy; -If the medication shortage is discovered at the time of medication administration, facility staff should immediately take the action as follows: [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure residents were free of any significant medication errors when staff failed to prime the insulin pens for two residents (Residents #156 and #100). The facility census was 105. Review of a facility policy titled General Dose Preparation and Medication Administration, revised 01/01/13, showed the following: -Facility staff should comply with facility policy regarding medication administration and should comply with applicable law and the State Operations Manual when administering medications; -Verify each time a medication is administered that it is the correct medication, at the correct dose, route, rate, and time, for the correct resident; -Follow manufacturer medication administration guidelines. Review showed the facility did not provide a policy specific to the administration of insulin using pre-filled pens. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely dental services for all residents when staff failed to identify the need for and obtain dental services for one resident (Resident #306) when his/her dentures were missing. The facility census was 105. Review of the facility's policy titled Dentures, Cleaning and Storing, dated 10/01/10, showed the following information: -Oral hygiene should be provided twice daily, unless documented by the physician as medically contraindicated, or the resident desires more frequent hygiene; -Clean dentures by brushing them with a denture cleaner or toothpaste; -Keep dentures in a cup in the bedside table until the resident is ready to replace them. 1. Review of Resident #306's face sheet (resident's information at a quick glance) showed an admission date of 07/29/24 and readmission date of 05/01/25. [...]

Inspectors wroteBased on interviews and record review, the facility failed to prevent misappropriation of resident property for all residents when one resident's (Resident #1) money was stolen from the lockbox kept in the resident's dresser in the facility. The facility census was 104. Review of the facility policy titled, Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown source, Exploitation, dated 02/08/18, showed the following: -All residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident/guest property; -The facility's policy strictly prohibits the abuse, neglect, exploitation and involuntary seclusion of residents. The policy also prohibits the misappropriation of resident's property. This policy against abuse, neglect, exploitation and misappropriation of resident property includes abuse by any other person; [...]

Inspectors wrote1. Please refer to event ID XMKY12, exit date 11/21/24. MO00245443, MO00244807 Based on interviews and record review, the facility failed to protect all residents from misappropriation of resident property when belongings for one resident (Resident #1), including purse, wallet, debit cards, ID cards, and money, went missing while the resident resided at the facility. The facility census was 106. Review of the facility policy titled, Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown source, Exploitation, dated 10/15/22, showed the following: -All of our resident have the right to be free from abuse, neglect, exploitation, and misappropriation of resident/guest property; -The facility's policy prohibits the misappropriation of resident's property; [...]

Inspectors wroteBased on interviews and record review, the facility failed to protect all residents from misappropriation of resident property when belongings for one resident (Resident #1), including purse, wallet, debit cards, ID cards, and money, went missing while the resident resided at the facility. The facility census was 106. Review of the facility policy titled, Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown source, Exploitation, dated 10/15/22, showed the following: -All of our resident have the right to be free from abuse, neglect, exploitation, and misappropriation of resident/guest property; -The facility's policy prohibits the misappropriation of resident's property; -This policy against abuse, neglect, exploitation and misappropriation of resident property includes abuse by any other person; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide care per standards of practice when facility staff failed to update orders and continue medications upon one resident's (Resident #1) return to the facility from the hospital, resulting in the resident not receiving any medication for one day. The facility census was 114. Review of the facility policy titled, admission of a Resident, effective October 2010, showed the following: -The admission process was intended to obtain all the information as possible about the resident for the development of comprehensive plans of care and to assist the resident in becoming comfortable in the facility; -To obtain a complete document of the physician's plan of care at the time of admission the resident's medical record should include treatments and medications; [...]

Inspectors wroteBased on interview and record review, the facility staff failed to employ a qualified dietary manager for food and nutrition services with accredited education in food service management. The facility census was 107. Review of the facility's job description titled Dietary Manager, dated 06/30/03, showed the following: -The Dietary Manager is to assist in planning, organizing, developing and directing the overall operation of the dietary department in accordance with current federal, state, and local standards governing the facility and as may be directed by the administrator and/or dietary consultant; -The Dietary Manager is to ensure that qualify nutritional services are provided on a daily basis and that the dietary department is maintained in a clean, safe and sanitary manner; [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure food was protected from possible contamination, and in accordance with professional standard of practice, while stored, prepared, and served when staff stacked wet dishes, failed to seal and date open food items, and failed to keep all of the kitchen areas clean and free of debris. The facility census was 107. 1. Review of the Food and Drug Administration (FDA) 2013 Food Code showed the following information: -Clean equipment and utensil shall be stored in a self-draining position that allows air drying; -Items must be allowed to drain and to air-dry before being stacked or stored; -Stacking wet items prevents them from drying and may allow an environment where microorganisms can begin to grow. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to keep the kitchen area clean and free of debris that could potentially come in contact with food being served. This has the potential to harm all residents. The facility census was 107. Record review of the facility policy titled, Cleaning Schedules, dated 8/11/2018, showed the following information: -The purpose of a cleaning schedule is to prevent the spread of bacteria that may cause food borne illnesses; -The cleaning schedule should include the frequency of cleaning for each person responsible. 1. Observation on 9/5/23, at 10:55 A.M., of the kitchen showed the following: - Thick cobwebs were found covering the window, above the sink window; -There is a light film of greasy-lint mixture, covering the air conditioner; [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure staff were aware of the emergency water policy and that a minimum amount of water was kept on hand at all times in case of emergency. The facility census was 107. Review of the facility's policy titled Water Service Interruption, undated, showed the following information: -Purpose to ensure water is available to the facility for both consumption by residents and staff, and for use in residents care, such as bathing; -As part of disaster planning, the facility should prepare a contingency plan, in the event of the loss of normal water supply, for each department; -The Administrator is to notify the appropriate state agency regarding interruption of water supplies to the facility; -All staff, residents, and visitors should be notified; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide showers/baths per resident preferences and failed to care plan shower/bathing preferences for three residents (Resident #92, #88, and #96). The facility census was 107. Review of the facility policy titled Hygiene and Grooming, dated 10/01/10, showed the following: -Guidelines for the provision of hygiene and grooming services are shower, tub, or complete bed bath, as needed; -Resident preferences for time of day, type of bath, and frequency of bath should be honored, to the extent possible; -Family members or social service staff may be called upon to assist when the residents refuse appropriate hygiene/grooming measures by nursing staff; -Residents should be encouraged to groom themselves whenever possible. 1. Interviews during the Resident Council Meeting held on 09/07/23, at 2:00 P.M., showed the following: [...]

Inspectors wroteBased on record review and interview, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge and failed to provide the ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) a copy of the transfer and discharge notification for four residents (Residents #75, #60, #68, and #43), of four sampled residents. The facility census was 107. Review of the facility policy,titled Transfer, Discharge and Therapeutic Leaves (including AMA (against medical advice)), dated 06/26/19, showed the following: -The resident has the right to refuse involuntary transfer out of a or discharge from the facility under certain circumstances; -Emergency discharges should occur only for medical reasons, or for the immediately safety and welfare of a resident or other resident; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide written information to the resident, or resident representative ,regarding the facility bed hold policy at the time of transfer to the hospital for three residents (Residents #75, #60, and #43) of four sampled residents. The facility census was 107. Review of the facility policy,titled Transfer, Discharge and Therapeutic Leaves (including AMA (against medical advice)), dated 06/26/19, showed the following: -The resident has the right to refuse involuntary transfer out of a or discharge from the facility under certain circumstances; -Emergency discharges should occur only for medical reasons, or for the immediately safety and welfare of a resident or other resident; -Emergency transfer procedures should include the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain informed consent for the use of side rails (bed rails) prior to installation for three residents (Resident #96, Resident #317, and Resident #311 and failed to obtain physician's orders for side use and failed to care plan side rail use for two residents (Resident #96 and #317). The facility's census was 107. Review of the facility's policy titled Bed Rail Use, effective 10/26/22, showed the following: -Bed rails are used to enable a resident to become more functionally independent and when the medical condition of the resident requires the use of a bed rail; -Bed rails could be considered a form of physical restraint; therefore, the need for bed rails should be identified in the resident assessment, and the plan of care, per guidelines and regulatory requirements; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all residents' a dignified existence when staff treated one resident (Resident #164) in an undignified and disrespectful manner and when staff did not utilize a dignity cover for one resident's (Resident #311) catheter (a flexible tube inserted in the bladder) bag while he/she ambulated in the hallway. The facility census was 107. Review of a facility policy entitled Federal Rights of Residents/Guest(s), dated 11/28/16 showed the following: -The resident has a right to a dignified existence; -The resident has the right to be treated with respect and dignity; -The facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life, recognizing each resident's individuality. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility to provide services to maintain good personal hygiene for all dependent residents when staff failed to provide sufficient bathing opportunities to two dependent residents (Resident #22 and #60) which resulted in the resident being noticeably dirty. The facility census was 107. #60 Review of the facility policy titled Hygiene and Grooming, dated 10/01/10, showed the following: -Guidelines for the provision of hygiene and grooming services are shower, tub, or complete bed bath, as needed; -Resident preferences for time of day, type of bath, and frequency of bath should be honored, to the extent possible; -Family members or social service staff may be called upon to assist when the residents refuse appropriate hygiene/grooming measures by nursing staff; -Residents should be encouraged to groom themselves whenever possible. 1. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure all staff were trained on where to find a resident's choice of code status (whether or not the wish to receive cardiopulmonary resuscitation (CPR - hands-on emergency intervention used to restore heartbeats and breathing) if a person's heart stops or he/she stops breathing), failed to obtain a physician's order for DNR code status for one resident (Resident #92), and failed to ensure one resident's (Resident #62) code status matched throughout the medical record. A sample of 14 residents were reviewed in a facility with a census of 107. Review of the facility policy, titled Advanced Directives and Refusal of Treatment, dated [DATE], showed the following: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to document assessment and monitoring of a pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) for one resident (Resident #327) of three sampled residents. The facility census was 107. Review of a facility policy entitled Protocol for Certified Nuse Aide (CNA) and Licensed Nurse Skin Inspections - Guidelines, revised 11/1/22, showed the following: -Intent is to identify any skin concerns in residents immediately and implement early intervention; -CNAs will conduct body inspections of residents at risk for pressure sores on a daily basis. Any skin concern identified by the CNA will be reported to assigned Licensed Nurse immediately; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate treatment and services to prevent possible urinary tract infection (UTI - (infection in any part of the urinary system, the kidneys, bladder) when staff failed to ensure the catheter drainage bag (bag collect urine from tube attach to a catheter (tube) that is inside the bladder) of one resident (Resident #68), with a prior history of UTIs, did not set or drag on the floor under the wheelchair or in the resident's room. Three residents were sampled in a facility with a census of 107. Review of the facility policy titled Urinary Catheter Care, dated 07/12/11, showed catheter tubing and drainage bags are kept off the floor to prevent contamination. 1. Review of Resident #68's face sheet (brief information sheet about the resident) showed the following: -admission date of 03/16/23; [...]

Inspectors wroteBased on interview and record review the facility failed to treat one resident (Resident #250) with dignity and respect. A sample of 23 residents was selected for review in a facility with a census of 114. Record review of facility's policy titled Resident/Guest Rights, dated November 2016, showed the following: -The resident/guest has the right to a dignified existence; -A facility must treat each resident/guest with respect and dignity and care for each resident/guest in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident/guest(s) individuality. 1. Record review of the Resident #250's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission dated 7/1/19; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff administered medications with an error rate of less than 5.0 percent when staff made two errors out of 29 opportunities, resulting in an error rate of 6.8 percent. This affected two residents (Resident #202 and Resident #46). The facility census was 114. Record review of the Tresiba (a long-acting insulin) website guidance, dated 9/2015, showed the following: -Prime (referred to as an air shot) the flex pen before each injection; -Turn the dose selector to select two units; -Press and hold the dose button; -Make sure a drop appears; -Priming the flex pens removes the air from the needle and cartridge that may collect during normal use and ensures the pen is working correctly; -Failure to prime the flex pen before each injection may result in administering an incorrect dose of insulin. [...]

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 pens prior to administration per manufacture recommendations and standards of practice for two (Resident #202 and Resident #46). The facility census was 114. Record review of the Tresiba (a long-acting insulin) website guidance, dated 9/2015, showed the following: -Prime (referred to as an air shot) the flex pen before each injection; -Turn the dose selector to select two units; -Press and hold the dose button; -Make sure a drop appears; -Priming the flex pens removes the air from the needle and cartridge that may collect during normal use and ensures the pen is working correctly; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the required two-step tuberculosis (TB - a potentially serious airborne bacterial infection affecting the lungs that spreads through the air when a person with TB coughs, sneezes, or talks) test was completed and documented completely for two residents (Resident #55 and #79). A sample of 23 residents was selected for review out of a census of 114. General requirements for Tuberculosis 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. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pneumococcal vaccines (vaccines used to prevent some cases of pneumonia, meningitis (swelling of brain and spinal cord membranes, typically caused by an infection), and sepsis (potentially life-threatening complication of an infection)) to two residents (Resident #55 and #250) following the residents' admission to the facility. The facility census was 114. According to the Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccine Timing for Adults, dated 11/30/15, showed the following: -Two pneumococcal vaccines are recommended for adults; -CDC recommends vaccinations with the pneumococcal conjugate vaccine (PCV13 or Prevnar 13) for all adults 65 years or older and people 19 through 64 years with certain medical conditions, including chronic (ongoing) conditions; [...]