Aspire Senior Living New Florence

Inspectors wroteBased on interview and record review, facility staff failed to implement an Antibiotic Stewardship Program with antibiotic use protocols and a system to monitor and track antibiotic use within the facility. The facility census was 50.1. Review of the facility's policy titled, Antibiotic Stewardship, undated, showed the purpose is to develop and implement protocols to optimize the treatment of infections by ensuring the residents who require an antibiotic, are prescribed the appropriate antibiotic. Reduced the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use. Develop, promote, and implement a facility wide system to monitor the use of antibiotics. Review of the facility's antibiotic stewardship program showed staff did not have a process in place to track and trend antibiotic usage. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to designate one or more individuals with specialized training in Infection Prevention and Control (IPC) as the Infection Preventionist (IP) for the facility's infection prevention and control program. The census was 50. 1. Review of the facility's Infection Preventionist (IP) Policy, undated, directed staff to designate a qualitied individual (s) to be responsible for implanting programs and activities to prevent and control infections. During an interview on 09/25/25 at 8:05 A.M., the administrator said the Assistant Director of Nursing (ADON) was the infection preventionist and left the facility September 9, 2025. The administrator said at this time the facility does not have an IP.

Inspectors wroteBased on observation, interview and record review, the facility staff failed to provide a clean, homelike and comfortable environment when staff failed maintain resident rooms, common areas, medical device equipment and the exterior of the building clean and in good repair. Facility census was 50.1. Review of the facility's External Environmental Services policy, dated 01/30/2024, directed staff to keep building exterior in good repair.2. Review of the maintenance records showed they did not contain documentation related to spa remodels.3. Review of the proposal for roof repairs, dated 08/12/25, showed the proposal did not contain approval signatures.4. Observation on 09/23/25 during the Life Safety Code tour showed:-The mansard roof on the north side of the facility contained multiple missing shingles which exposed the wood decking. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to complete an entrapment assessment for two residents (Resident #2 and #38) of two sampled residents with bed rails. The facility census was 50. 1. Review of the facility's policy titled, Bed/Assist Bars Use in Long-Term Care, dated 09/17/25, showed staff are directed: -Nursing/Therapy staff must perform a risk assessment prior to implementation that considers entrapment risk;-Findings and rationale must be documented in the resident's care plan;-Ensure proper positioning to minimize entrapment and injury risk. 2. Review of Resident #2's comprehensive minimum data set (MDS), a federally mandated assessment tool, dated 06/26/25, showed staff assessed the resident as:-Cognitively intact;-Diagnoses of a seizure disorder or epilepsy;-Bed rails not used as restraint in bed. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to develop and implement an effective Quality Assurance (QA)/Quality Assurance Performance Improvement (QAPI) program which included documentation and implementation of on-going systemic issues with resolution. The facility census was 50.1. Review of the facility's Quality Assurance and Performance Improvement Plan, undated, showed, it is the purpose of this facility-wide performance improvement process to include identifying and implementing opportunities to improve the quality of resident care and quality of life, as well as other measures of organizational performance. Meeting quarterly with key personal attending to coordinate this program. Review of the Performance Improvement Program, dated 09/03/25, showed, area of concern: QAPI has not been previously done. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD) (a serious type of pneumonia (lung infection) caused by Legionella bacteria, which places all residents at risk of exposure which could lead to illness. Staff failed to ensure the two-step purified protein derivative (PPD) (skin test for tuberculosis bacteria (TB)) was completed in accordance with their policy and on file for five employees (Dietary D, Certified Medication Technician (CMT) E, Housekeeper F, Social Services, and Certified Nursing Assistant (CNA) G) out of ten employee files reviewed. [...]

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 at the time of transfer to the hospital for three residents (Resident #22, #38, and #49) out of three sampled residents. The facility census was 50.1. Review of the facility's policy titled, Bed Hold Policy Guidelines, undated, showed the facility will notify residents and/or their representative of the bed hold policy guidelines. The bed hold notification shall be given upon admission to the facility, at the time of transfer to the hospital or leave, and at the time of non-covered therapeutic leave. 2. Review of Resident #22's medical record showed staff documented the resident discharged from the facility to the hospital on [DATE] and returned on 05/01/25. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to develop and implement a comprehensive person-centered care plan to reflect the care needs for three residents (Resident #2, #30, and #41) out of 13 sampled residents. The facility census was 50.1. Review of the facility's policy titled, Care Plan Policy, undated, the care plan is designed to identify each resident's strengths, needs, goals, and preferences and to guide the delivery of quality, coordinated care that promotes the highest practicable physical, mental, and psychosocial well-being. [...]

Inspectors wroteBased on interview, and record review, facility staff failed to ensure care plans were reviewed and revised with changes in the resident's needs for seven residents (Resident #5, #14, #16, #19, #23, #38 and #41) out of 13 sampled residents. The facility census was 50. R 1. Review of the facility's policy titled, Care Plan Policy undated, showed the care plan is designed to identify each resident's strengths, needs, goals and preferences and to guide the delivery of quality, coordinated care that promotes the highest practicable physical, mental, and psychosocial well-being. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure Certified Nurse Aid (CNA) G, nurse aid (NA) H and CNA I received a minimum of 12 hours of ongoing education annually. The facility census was 50.1. Review of the Facility's Nurse Aide Regular In-Service Training policy, dated 01/20/24, showed the in-service training must be sufficient to ensure the continuing competence of the nurse aides but must be no less than 12 hours per year, include dementia training and resident abuse prevention training, and for nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired. Review of the facility's Resident Matrix, dated 09/22/25, showed staff documented 16 residents who resided in the facility with diagnoses of dementia and/or Alzheimer's disease. [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week. The facility census was 46. 1. Review of the facility's Registered Nurse policy, dated 01/30/25, showed except when waived, the facility must use the services of a registered nurse for at least eight consecutive hours a day, seven days a week. 2. Review of the Facility Assessment, revised 05/15/25, showed the facility is to staff at least one RN at least eight hours per day, seven days a week. 3. Review of the facility's RN Staffing assignments, dated 06/01/25 through 06/30/25, showed staff did not provide the services of an RN for eight consecutive hours per day on 06/11/25, 06/13/25, and 06/22/25. 4. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to post the required nurse staffing information to include the facility name, current date, resident census, total number of staff and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift, daily. Facility staff failed to keep the required daily staffing records. The facility's census was 46.1. Review of the facility's Nurse Staffing Information policy, dated 01/30/25, showed staff are directed as follows:-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: [...]

Inspectors wroteSee event ID PY0C12. Based on interview, and record review, facility staff failed to maintain professional standards of practice when staff failed to document wound treatments for one resident (Resident #1), whose wound became infected, out of three sampled residents and failed to perform neurological assessments for one resident (Resident #1) out of three sampled residents after a fall. The facility census was 51.

Inspectors wroteBased on interview, and record review, facility staff failed to maintain professional standards of practice when staff failed to document wound treatments for one resident (Resident #1), whose wound became infected, out of three sampled residents and failed to perform neurological assessments for one resident (Resident #1) out of three sampled residents after a fall. The facility census was 51. 1. Review of the facility's policy titled, Physician Orders, dated 02/2022, showed staff are directed to follow physician's orders. Physician's orders will be entered into the electronic medical record (EMR) as soon as practicable once received from the physician. Orders will be carried out as per the physician. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to follow applicable laws and regulations when the staff failed to screen four staff (Licensed Practical Nurse (LPN) D, Certified Nurse Assistant (CNA) J, Dietary Aide (DA) L, and DA M) of 10 staff sampled for Tuberculosis ((TB) a bacterial infection that affects the lungs). The facility staff failed to ensure dietary staff performed hand hygiene as often as necessary using approve techniques to prevent cross-contamination. The facility census was 54. 1. Review of the facility's policy titled TB Testing and Screening-Employee, revised December 2010 showed: -All employees and volunteers of eight or more hours per month will receive a Mantoux two-step test, a skin test that can help determine if someone has TB; -Employees and volunteers will received the first step TB test prior to resident contact. 2. [...]

Inspectors wroteBased on record review and interview, facility staff failed to maintain an accurate accounting system for resident fund bank statement matched the reconciliation for March 2024 to July 2024, and failed to provide quarterly bank statements to the residents. The facility held funds for 25 residents. The facility census was 54. 1. Review of the facility's policy titled Resident Trust Fund, undated, showed: -Upon written request of the resident or responsible party, the facility must hold, safeguard, manage, and account for the resident's personal funds through the Resident Trust Fund; -Transactions are to be entered daily or as they occur so that the balance for each resident can be accessed at anytime during the day; -Resident statements will be sent out quarterly. 2. [...]

Inspectors wroteBased on record review and interview, facility staff failed to provide refunds of personal funds to residents from the facility operating account within 30 days for six residents (Resident #212, #209, #211, #207, #208, and #210) who were discharged from the facility. The facility census was 54. 1. Review of the facility's policy titled Resident Trust Fund, undated, showed upon written request of the resident (or responsible party), the facility must hold, safeguard, manage, and account for the resident's personal funds. 2. Review of the facility's-maintained Account Receivable Aging report, dated 09/05/24, showed resident's with personal funds held in the facility operating account: -Resident #212 had a balance of $5671.11 with a discharge date of 06/24/23. -Resident #209 had a balance of $78.80 with a discharge date of 10/15/23; [...]

Inspectors wroteBased on interview and record review, facility staff failed to complete pre-employment screenings Criminal Background Check (CBC), Employee Disqualification List (EDL) verification, Family Care Safety Registry (FCSR), and Certified Nursing Aide (CNA) Registry for six employees (Housekeeper N, Dietary Aide (DA) K, Licensed Practical Nurse (LPN) D, CNA J, DA L, and CNA I) of 10 employees sampled. The facility census was 54. 1. Review of the facility's policy titled Recruitment and Hiring, revised March 2024, showed: -The facility will follow all state and federal laws regarding hiring practices; -The Human Resources (HR) department will process all pre-hire screenings within one or two business days of receiving documentation from the hiring manager; -CBC; -EDL verification; -FCSR verification; -Verify all license and certification; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to develop and implement a comprehensive person-centered care plan for four residents (Resident #5, #31, #44, and #48) out of 15 sampled residents. The facility census was 54. 1. Review of the facility's policy titled Comprehensive Care Plans Policy and Procedure, revised [DATE], showed: -The comprehensive care plan contents include areas identified through the Minimum Data Set (MDS) (a federally mandated assessment tool) process, the resident's medical condition, and other risk or problem areas identified through assessment; -Care plan is to be updated quarterly and as needed to reflect the resident's current needs, goals, and interventions. 2. Review of Resident #5's Significant Change MDS, dated [DATE], showed staff assessed the resident as: -Cognition impairment; -Received hospice services. [...]

Inspectors wroteBased on interview and record review, facility staff failed to notify one resident's (Resident #1) family and physician in a timely manner when staff identified the residents second and third toes on his/her right foot swollen, red, white, macerated, draining serosanguinous fluid (contains or relates to both blood and the liquid part of blood (serum) which resulted in the resident being sent to the hospital and his/her second right toe amputated. The facility census was 50. 1. Review of the facility policy change of condition, revised February 2019, showed staff are directed to observe, record, and report any condition change to the attending physician to ensure proper treatment will be implemented. Review showed staff are directed to notify the resident's responsible party. 2. [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide restorative therapy for three residents (Resident #1, Resident #2, and Resident #3) with restorative therapy orders. The facility census was 54. 1. Review of the facility's policy on physician's orders, February 2022, showed orders will be carried out as per the physician. 2. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 9/17/23, showed staff assessed the resident as follows: -Dependent on staff for extensive assistance with transfers; -Did not display walking in corridor; -Diagnosed as unsteady on feet and muscle weakness. Review of the resident's plan of care, dated 9/28/23, showed staff documented the resident with limited physical mobility due to weakness and recent hospitalization. [...]

Inspectors wroteBased on record review and interview, facility staff failed to correctly document use of bed rails as a restraint for residents who used bed rails instead for a positioning or mobility aid in the restraint section (section P100) of the Minimum Data Set (MDS), a federally mandated resident assessment tool, for three residents (Residents #3, #34 and #41). The facility census was 51. 1. Review of the Restraints and Alarms section of the Resident Assessment Instrument (RAI) Manual showed the following: -Physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. 2. Review of the facility's Bed Rail Policy, dated 2017, showed the definition of physical restraints defined as: [...]

Inspectors wroteBased on observation and interview, facility staff failed to ensure the residents' environment remained free of accident hazards by failing to ensure disposable razors were not accessible to two identified residents (Resident # 25 and #46) and one unidentified resident. Additionally, staff failed to ensure disposable razors were stored behind a locked cabinet in two shower rooms. The facility census was 51. 1. Review of the facility's policies showed the facility did not provide a policy to direct staff on how to properly store razors. 2. Observation on 10/24/22 at 12:16 P.M. showed Resident #25 and Resident #46 shared a bathroom. Review of Resident #25's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/29/22, showed staff assessed the resident as follows: -No Cognitive impairment; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to complete an assessment of the resident's risk from using side rails/bed rails, complete initial and/or annual entrapment assessments, and/or obtain informed consent for the use of side rails for six (Residents #3, #23, #34, #41, #45 and #46). The facility census was 51. 1. Review of the facility's Bed Rail Policy, dated 2017, showed staff are directed to: -Conduct a duo-faceted approach to achieve quality outcomes, including 1) regular bed maintenance and 2) individual bed rail evaluations in response to the requirement of providing safe, clean, comfortable, and homelike environment, the facility's regular maintenance program will include regular inspection of all bed systems (e.g. rails, frames, mattresses, and operational components) to assure they are clean, comfortable and safe. -Overview of the U.S. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to appropriately sanitize a multi-use glucometer (a device for monitoring blood sugars) before and after use for four residents (Resident #2, #35, #36, and #48) to prevent the spread of infection causing contaminants, failed to provide catheter care in a manner to prevent the spread of infection for three residents (#5, #25, and #39) and failed to administer the Two-step Tuberculin (TB) testing as per policy for two out of 10 sampled staff members (Dietary J and Registered Nurse (RN) K). The facility census was 51. 1. Review of the facility's Cleaning and Disinfecting Blood Glucose Meters policy, undated, showed: It is the policy of the facility to clean and disinfect blood glucose meters that are shared between residents; [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide notice related to transfer or discharge of residents to the hospital to the Ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) for one resident (Resident #47). The facility census was 51. 1. Review of policies requested from the facility showed they did not provide a policy in regards to the notification of the resident's representative and the ombudsman of a transfer to a hospital. Review of an email on 10/20/22 at 12:39 P.M., the ombudsman wrote the facility does not send him/her monthly notifications of transferred residents. Review of Resident #47's medical record showed the following: -discharged to the hospital on [DATE]; -Resident returned to the facility on [DATE]; [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide written information to the resident and/or the resident's representative of their bed hold policy at the time of transfer to the hospital for one sampled resident (Resident #47). The facility census was 51. 1. Review of the facility's Resident Handbook, undated, showed the following: -If you need to transfer to a hospital, your bed may be guaranteed with a paid bed hold; -Making these arrangements will ensure that a bed is available upon your return; -This will alleviate your family's responsibility to remove your belongings during your hospital stay. Review of the facility's Resident Rights, revised October 2018, showed Rights During Discharge/Transfer included, Notice of the right to return to the facility after hospitalization or therapeutic leave. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to ensure staff followed acceptable standards of practice for two residents (Resident #3 and #44) when staff left medications unattended with the resident. The facility census was 51. 1. Review of the facility's policy General Dose Preparation and Medication Administration revised 05/01/10 showed that during medication administration, facility staff should observe the resident's consumption of the medications(s). 2. Review of Resident #3's Physician Order Sheet (POS), dated 12/22/21 showed an order for Miralax Powder 17 gram (gm)/scoop, Give one scoop by mouth every 24 hours as needed for constipation. Observation on 10/24/22 at 12:14 P.M., showed Certified Medication Technician (CMT) H left the Miralax 17 gm unattended with the resident. 3. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility staff failed to provide proper respiratory care for three residents (Residents #19, #46, and #301), when staff failed to regularly change oxygen tubing as directed in their policy. The facility census was 51. 1. Review of the facility's Oxygen Administration Policy, dated 2/2019, showed staff is directed to the following: -Change tubing, cannula, and humidifier bottle weekly. During an interview on 10/27/22 at 4:48 P.M., the Administrator said nurses are responsible for changing out oxygen tubing. They should have on order on the Medication Administration Record (MAR) that includes how often they should be changing out the tubing. Once the oxygen tubing is changed, the nurses should label the tubing with the date and their initials. 2. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to ensure one Nurse Aide (NA) completed the nurse aide training program within four months of his/her employment in the facility. The census was 51. 1. Review of the facility's Nursing Services Competency Evaluations policy, undated, showed the following: -Prior to hire, Human Resources will verify from the registry that the nurse aide has completed the training and competency evaluation program approved by the State; -Nursing assistants may onboard for less than 4 months if enrolled in a State approved program or deemed or determined competent as provided unless the individual: [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to store controlled medications (substances that have an accepted medical use (medications which fall under United States (US) Drug Enforcement Agency (DEA) Schedules II-V), have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) in a separately locked, permanently affixed compartment. The facility census was 51. 1. Review of the facility's Controlled Substance Prescription policy, dated July 2021, showed controlled substance medications are stored at the facility under double lock on the medication cart separate from all other medications and counted at each change of custody. The access key to controlled medications is not the same key that allows access to other medications. [...]

Inspectors wroteBased on interview and record review the facility staff failed to maintain an approved surety bond sufficient to ensure protection of all resident funds. The facility census was 51. 1. Review of the facility's Security of Personal Funds Deposited Policy, undated, showed it is the policy of the facility to purchase a surety bond, or provide self- insurance to assure the security of all personal funds of residents deposited within the facility. A surety bond equal to one and half times the average funds in the resident fund account will be maintained by the business office. The business office will inform the facility's management services if the amount of the surety bond needs to be adjusted upward. Review of the resident trust account for October, 2021 through September 2022, showed an average monthly balance of $47,000.00 which requires a surety bond of $70,500.00. [...]

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. The facility census was 51. 1. Review of the facility's Resident Rights, dated October 2018, showed: -The resident has a right to a dignified existence with freedom from abuse, neglect, exploitation, and misappropriation of property; - The resident has a right to be fully informed of the contact information for the long-term care ombudsman program and the state survey agency. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to post the required nurse staffing information, which included the total number of staff and the actual hours worked, by both licensed and unlicensed nursing staff directly responsible for resident care, per shift, and on a daily basis. The facility census was 51. 1. Review of the facility's Posting of Nursing Staff policy, dated 4/8/2020, showed the following: -It is the policy of this facility to be in compliance with all federal requirements related to the posting of nursing staffing; -Each morning the staffing for that day will be posted identifying the number of Registered Nurses (RN), Licensed Practical Nurses (LPN), Certified Medication Technicians (CMT) and Certified Nursing Assistants (CNA) on each shift; [...]

Inspectors wroteBased on interview and record review, the facility staff failed to designate one or more individuals with specialized training in Infection Prevention and Control (IPC) as the Infection Preventionist (IP) for the facility's infection prevention and control program. The census was 51. 1. Review of the Center for Disease Control (CDC)'s Preparing for COVID-19 in Nursing Homes policy, updated on 11/20/20, showed facilities should assign at least one individual with training in IPC to provide on-site management of their COVID-19 prevention and response activities, because of the breadth of activities for which an IPC program is responsible, including developing IPC policies and procedures, performing infection surveillance, providing competency-based training of health care providers (HCP), and auditing adherence to recommended IPC practices. [...]