Aspire Senior Living Malden

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor and keep three resident's (Residents #1, #29, and #40) equipment in good, working order. The facility also failed to maintain a safe, clean, comfortable and homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 39. Review of the facility's policy titled, Safe Environment, dated 01/30/25, showed: - The resident has a right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely; - Housekeeping and maintenance services necessary to maintain a sanitary, including but not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored, orderly, and comfortable interior; [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) for four residents (Residents #18, #27, #29 and #33) out of 12 sampled residents. The facility census was 39. Review of the facility's policy titled, Resident Assessment Instrument (RAI/MDS) Process, last reviewed, January 2025, showed: - One of the functions in the RAI/MDS process is to gather data to develop comprehensive and individualized care plans that meet the medical, nursing, mental and psychosocial needs of each resident. Each care plan will describe services furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff utilized safe transfer techniques for three residents (Residents #29, #32, and #37) when staff failed to transfer the resident with the assist of a gait belt (a device used to aid in the safe movement of a person from one place to another) out of four sampled residents. The facility census was 39. Review of the facility's policy titled, Gait Belt Use, undated, showed: - The purpose of a gait belt is to provide better control and balance while assisting a resident with ambulation or transfer; - Assist the resident to a sitting position; - Apply the belt to the resident's waist; tighten to fit snugly with the buckle at the side; - Bring the resident to a standing position while straightening your knees; - After the resident is standing, the belt provides assistance stabilizing the turning of the resident. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to establish a system of records for the receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation of controlled medications to ensure nursing staff signed at the beginning and the end of each shift for one medication cart out of two sampled medication carts. The facility's census was 39. Review of the facility's policy titled, Narcotic Count, revised, March 2015, showed: - The purpose of this policy is to complete a physical inventory of narcotics at each shift change to identify discrepancies; - One Registered Nurse (RN), Licensed Practical Nurse (LPN) or Certified Medication Technician (CMT) going off duty and one RN, LPN, or CMT coming on duty must count and justify accuracy of the narcotics supply for each individual resident at the change of each shift; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than five percent (%). There were 30 opportunities with four errors made, resulting in an error rate of 13.33% for three residents (Residents #8, #10 and #30) out of six sampled residents. The facility's census was 39. Review of the facility's policy titled, Insulin Administration, last revised May 2012, showed: - The nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use. Review of the Humalog/lispro (a rapid insulin that helps lower mealtime blood sugar spikes) Kwik Pen (insulin in a pen-type device) instructions, revised July 2023, showed: - Prime the pen by turning the dose knob to two units; - Hold the pen with the needle pointing up; [...]

Inspectors wroteBased on interview and record review, the facility failed to document likes and dislikes on the meal card and failed to follow the preferences for one resident (Resident #35) out of 12 sampled residents. The facility census was 39. Review of the facility's policy titled, Resident's Food Likes and Dislikes, last reviewed January 2025, showed: - A dietary assessment will determine the resident's food likes and dislikes; - On admission, or within 24 hours after the resident's admission, the Dietary Manager (DM) will interview the resident to determine the resident's food likes and dislikes; - A written record will be maintained of the resident's likes and dislikes; - Residents will be consulted periodically to determine if any changes need to be made in order to meet the resident's needs. 1. Review of Resident #35's medical record showed: - An admission date of 05/03/24; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These deficient practices had the potential to affect all residents. The facility census was 39. Review of the facility's policy titled, Storage of Food and Refrigeration, dated 01/30/24, showed: - Ensure food needing refrigeration is properly stored to prevent food-borne illness; - All containers must be labeled with the contents and date the food item was placed in storage. Review of the facility's policy titled, Dish Washing, dated 01/30/25, showed: - Ensure dishes are properly sanitized after each use; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement enhanced barrier precautions (EBP) during tracheostomy (trach - a surgical opening in the neck through the wind pipe to allow air into the lungs) care (sterile suctioning and dressing change) for one resident (Resident #7) out of one sampled resident. The facility failed to implement enhanced barrier precautions EBP and proper infection control practices when staff administered medications through a peripherally inserted central catheter (PICC- a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) for one resident (Resident #27) out of one sampled resident. The facility also failed to maintain proper glove use during peri care for one resident (Resident #37) out of six sampled residents and one resident (Resident #32) outside the sample. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide and document that residents received or declined the influenza (a viral infection of the respiratory system) immunizations and failed to provide and document pertinent education to residents or resident representatives regarding benefits, side effects, or warnings of the influenza immunization for two residents (Residents #37 and #40) out of five sampled residents. The facility's census was 39. Review of the facility's policy titled, Immunizations of Residents, last reviewed January 2024, showed: - The purpose of this policy is to ensure all residents are afforded the opportunity to receive vaccinations for preventable diseases; - Administering essential immunizations/vaccinations is key to the health and well-being of long-term care residents. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to conduct regular inspections of all bed frames, mattresses, side rails, and enabler bars as part of a regular maintenance program for one resident (Resident #27) out of two sampled residents. The facility's census was 39. Review of the facility's policy titled, Bed and Bed Rail Maintenance to Reduce/Prevent Entrapment, last reviewed January 2024, showed: - This facility will assess the bed and bed rails for each resident and document such assessment prior to the use of bed rails for every resident. If the resident uses a different bed or when bed rails are added, the assessment and subsequent documentation must be repeated. Review of the facility's policy titled, Bed Rails, last reviewed January 2025, showed; - This facility will attempt to use appropriate alternatives prior to installing a side or bed rail; [...]

Inspectors wroteBased on observation, record review and interview the facility failed to maintain a safe, clean, comfortable and homelike environment. This deficient practice had the potential to affect all residents at the facility. The facility census was 38. Review of the facility's policy titled, Safe Environment, undated, showed: - A safe, clean, comfortable and homelike environment environment, allowing the resident to use his or her personal belongings to the extent possible; - This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Observations made on 06/18/24 at 12:22 P.M. and 06/20/24 at 8:52 A.M., of the 100 hall and unit, showed: - Several areas of exposed sheetrock and peeled paint on the right side wall by bed 1 in resident room [ROOM NUMBER]; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments, a federally mandated assessment tool to be completed by the facility staff, for one resident (Resident #8) out of 12 sampled residents. The facility census was 38. Review of the facility's policy titled, Resident Assessment, undated, showed: - This facility conducts initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a care plan with specific interventions to meet individual needs of two residents (Residents #1 and #35) out of 12 sampled residents. The facility census was 38. Review of the facility's policy titled, Comprehensive Care Plans, not dated, showed: - The purpose of this policy is 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 medical, physical, mental, and psychosocial needs. - Measurable objectives and timeframes to meet the resident's medical, nursing and mental/psychosocial needs that are identified in the comprehensive assessment utilizing the Resident Assessment Instrument (RAI) process; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to appropriately assess the use of bed rails, review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to using bed rails and appropriately plan care for one resident (Resident #34) out of 12 sampled residents. The facility census was 38. Review of the facility's policy titled, Restraints-Physical-Side Rails, not dated, showed: - Assess resident's need for restraint use; - Obtain physician's order for restraint; - Develop or review resident care plan for type of restraint, reason for use, alternate methods to be used and method application; - Determine the type of side rails to be used; - Determine the medical symptoms to be treated with the side rails; - Involve the resident and the resident's representative in planning for side rail use. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide food of the resident's preferences, and failed to document likes and dislikes on the meal cards for three residents (Residents #18, #34, and #38) out of 12 sampled residents and one resident (Resident #37) outside the sample. The facility census was 38. Review of the facility's policy, titled, Resident's Food Likes and Dislikes, not dated showed: - A dietary assessment will determine the resident's food likes and dislikes; - On admission, or within 24 hours after the resident's admission, the Dietary Manager will interview the resident to determine the resident's food likes and dislikes; - A written record will be maintained of the resident's likes and dislikes. - Residents will be consulted periodically to determine if any changes need to be made in order to meet the resident's needs. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct at least twelve hours of nurse aide in-service education per year. This affected two Certified Nurse Assistants (CNA) A and CNA B out of two sampled CNA's. The facility's census was 38. Review of the facility's policy titled, Nurse Aide Regular In-Service Training,, dated 01/30/24 showed: - The facility's in-service training must be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year. 1. Review of the in-service record for CNA A showed: - A hire date of 01/24/23; - A total of eight hours and 25 minutes of annual in-service training for January 2023 through January 2024; - Less than twelve hours of in-service education for January 2023 through January 2024. 2. Review of the in-service record for CNA B showed: - A hire date of 05/13/23; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were informed of resident rights and responsibilities information verbally and in writing. The facility census was 38. 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, self-determination, and communication with and access to persons and services inside this facility. This facility promotes and protects the exercise of all resident's rights; - Residents will be informed of the resident rights in writing upon admission. This may be accomplished by giving them a copy of the Resident Rights or the Resident Handbook; - The list of resident rights will be available for residents to review at any time. [...]

Inspectors wroteBased on interview and record review, the facility failed to send monthly transfer logs to the representative of the Office of the State Long-Term Care (LTC) Ombudsman (a program that advocates for residents, provides information and help resolve problems) in a timely manner. The facility's census was 38. Review of the facility's policy titled, Transfer and Discharge, Voluntary - Notification of State LTC Ombudsman, undated, showed: - Provide State LTC Ombudsman with notification of voluntary resident transfers and discharge from this facility as required by guidance in F623; also to provide added protection to residents from being appropriately discharged , provide residents with access to an advocate who can inform them of their options and rights, and to ensure that the Office of State LTC Ombudsman is aware of the facility practices and activities related to transfers and discharges; [...]

Inspectors wroteBased on observation and interview, the facility failed to post daily menus and a list of available substitutions for residents to reference. The facility census was 38. Review of the facility's policy titled, Menu Posting and Display, undated, showed: - All menus for the current week are clearly posted and dated to adequately document meals that are to be served and to guide staff assisting with the meal service; - The dated menu for the current week is posted in areas easily accessible to residents and families. Observations on 06/17/24 at 9:58 A.M., 06/18/24 at 8:45 A.M. and 06/19/24 at 10:05 A.M., of the main dining room and the unit dining room, showed: - No daily menus posted; - No list of available substitutions. During an interview on 06/18/24 at 12:15 P.M., Activity Director (AD) said he/she has never seen daily lunch menus posted. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to control the fly population in the facility. This deficient practice had the potential to affect all residents. The facility census was 38. Review of the facility's policy titled, Pest Control Program, dated 04/01/24, showed: - It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents; - Facility will maintain a report system of issues that may arise in between scheduled visits with the outside pest service and treat as indicated; - Facility will utilize a variety of methods in controlling certain seasonal pests, i.e. flies. These will involve indoor and outdoor methods that are deemed appropriate by the outside pest service and state and federal regulations. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This has the potential to affect all residents. The facility census was 29. Review of the facility's policy titled, Storage of Food in Refrigeration, showed: - Ensure food needing refrigeration is properly stored to prevent food-borne illness; - Fresh fruits, vegetables, eggs, cheeses, and other perishable items will be stored in refrigeration of at 41 degrees Fahrenheit (F) or below; - Store raw meats on the bottom shelves to prevent contamination of other perishable items; - Food being returned to storage after cooking or preparation must be covered; - All containers must be labeled with the contents and date food item was placed in storage; [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the dumpster was maintained to keep pests out and/or to keep the garbage contained in the dumpster. This failure had the potential to affect all residents. The facility census was 29. Review of the facility's policy titled, Trash Pickup and Recycling, undated, showed: - Provide a clean, safe, and sanitary environment; - Trash will be collected from each resident room daily. Review of the facility's policy titled, Housekeeping, undated, showed: - Garbage and trash are to be stored in designated areas; - Trash bags are to be secured tightly when removed from trash container to prevent spills or contamination; - Gloves should be worn when removing and handling trash; - Receptacles are to be kept clean and covered with no trash placed on top; - Garbage and trash should be collected according to the facility schedule; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a safe, clean, comfortable, and homelike environment. The deficient practice had the potential to affect all residents in the facility. The facility's census was 29. Review of the facility's policy, Housekeeping, undated, showed: - Establish standards of cleanliness and consistency in the way in which resident rooms and common areas are cleaned and maintained; - The facility will be cleaned on a regular basis according to a specified cleaning schedule and according to federal/state guidelines; - The floors, walls, ceiling, and vents are to be kept clean; - Resident's room floors are to be clear of spills, stains, and debris; - If nursing personnel notice any of these sanitary violations occurring in the resident's room, housekeeping and/or maintenance should be notified promptly; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a Preadmission Screening and Resident Review (PASRR) (a federally mandated preliminary assessment to determine whether a resident may have a mental illness or an intellectual disorder to determine the level of care needed) for one resident (Resident #7) out of two sampled residents. The facility census was 29. Review of the facility's policy titled, Preadmission Screening for Individuals with a Mental Disorder/Intellectual Disability, undated, showed: - The purpose is to ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission; - The screening helps to ensure individuals are not inappropriately placed in nursing homes for long term care; - All applicants to a Medicaid certified nursing facility be evaluated for a serious MD and/or ID; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician's orders pertaining to the flush amount with the tube feeding for one resident (Resident #24) out of two sampled residents. The facility also failed to obtain a physician's order for oxygen (O2) therapy for one resident (Resident #27) out of six sampled residents. The facility's census was 29. Review of the facility's policy titled, Receiving and Recording Medication Orders, undated, showed: - A current list of orders will be maintained in the medical record of each resident; - Orders will be written/signed and placed in chronological order in the medical record; - When recording orders for routine medications, specify the type, route, dosage, frequency, and strength of the medication ordered; - When recording oxygen orders, specify the rate of flow, route, and rational; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store medications in a safe and effective manner five out of 13 times when staff left the unattended medication cart unlocked. This had the potential to affect all residents. The facility census was 29. Review of the facility's Medication Administration policy, not dated, showed: - Keep the medication cart in view at all times; - Lock the cart when not standing next to it or working from it; - Keep the key to the medication cart with you at all times, never leave key in lock on the cart. Observations on 04/27/23 of medication pass showed: - At 11:21 A.M., Certified Medication Technician (CMT) B entered Resident #6's room to administer the resident's medications and left the keys in the lock of the unlocked medication cart. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide and document residents received or declined appropriate immunizations and failed to provide and document pertinent education to residents or a resident's representative regarding the benefits, side effects, or warnings of those immunizations for five residents (Residents #2, #6, #24, #26, and #27) out of five sampled residents. The facility census was 29. Review of the facility's policy titled, Influenza and Pneumococcal Immunizations - Residents, undated, showed: - Upon admission to the facility, permission must be obtained from the resident or representative to administer pneumococcal vaccine and influenza vaccine annually (in the fall), unless contraindicated; - All residents will be assessed for pneumococcal vaccine status upon admission; [...]

Inspectors wroteBased on interviews, record review, and document review, the facility failed to ensure COVID-19 (a respiratory disease caused by SARS-CoV-2) vaccination education and declinations were documented in the medical record for five residents (Resident #2, #6, #24, #26, and #27) out of five sampled residents reviewed for immunization documentation. The facility census was 29. Record review of the facility's policy titled, COVID-19 Vaccination-Residents, undated, showed: - Licensed nursing staff and/or physicians/physician extenders will provide residents and/or resident representatives with information necessary to make an informed consent including corresponding vaccine Fact Sheets; - Informed Consent forms will be reviewed with each resident and/or resident representative. [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct at least twelve hours of nurse aide in-service education per year. This affected two out of two sampled Certified Nurse Assistants (CNA). The facility's census was 29. Review of the facility's policy titled, Nurse Aide Regular In-Service Training, undated, showed: - In-service training must be no less than 12 hours per year; - Dementia care and resident abuse prevention training must be included. 1. Review of the in-service record for CNA B showed: - A hire date of 09/01/21; - A total of zero hours of annual in-service training for September 2021 through September 2022; - Less than twelve hours of in-service education for September 2021 through September 2022. 2. Review of the in-service record for CNA C showed: - A hire date of 12/20/21; [...]