Aspire Senior Living Oak Grove

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #1) was free from physical abuse. On 2/5/25 Resident #2 struck Resident #1 on the left side of his/her face, resulting in a black eye out of four sampled residents. The facility was census was 87 residents. The Administrator was notified on 2/14/25 of the past noncompliance which began on 2/5/25. The facility inserviced all staff on the resident to resident abuse policy and interventions. The deficiency was corrected 2/5/25. Review of the facility's undated Abuse Prevention Program policy showed: -Abuse was the willful infliction of injury, unreasonable confinement, intimidation or punishment resulting in physical harm, pain or mental anguish. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify in writing the Durable Power of Attorney (DPOA) of resident room and roommates changes for two sampled residents (Resident #1 and #3). The facility census was 85 residents. Review of the undated facility Resident Rights Policy showed the resident has the right to receive written notice before the resident's room or roommate in the facility is changed, including the reason for the change. Review of the undated facility Notification of Changes Policy showed: -Purpose to Ensure resident and/or resident representative notification of specific changes during the resident's stay in the facility. -The facility must promptly notify the resident and the resident representative, if any, when there is: --A change in room or roommate assignment or, --A change in resident rights under Federal or State law or regulations. 1. [...]

Inspectors wroteBased upon interview and record review, the facility failed to use a binding arbitration agreement that was optional, and stated residents and/or their representatives were not compelled to sign the Arbitration Agreement as a condition of admission and could rescind the arbitration agreement within 30 calendar days of signing. This affected two residents (Resident #64 and #45) out of three sampled residents. This had the potential to affect all residents who had previously signed mandatory arbitration agreements. The facility assessment was 86 residents. 1. Review of the facility's Arbitration Agreement, undated, showed: -An Alternative Dispute Resolution Addendum showing: --The addendum was attached and made a part of the admission Agreement between the facility and resident. [...]

Inspectors wroteBased on interview and record review, the facility failed to offer one sampled resident (Resident #64) advanced directive election when he/she wanted to formulate advanced directives to identify his/her family member as his/her Durable Power of Attorney (DPOA legal document that gives someone the ability to make important decisions for you) if he/she was unable to voice his/her wants/needs, out of 18 sampled residents. The facility census was 86 residents. Review of the undated facility policy titled Durable Power of Attorney for Health Care (DPOA) showed: -Residents will be given the option of completing a DPOA for HealthCare if they have not already done so. DPOA for Health Care does not go into effect unless the resident is unable to make a health care decision because of being unconscious or having significant dementia. This option will be presented to a resident on admission. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three out of three sampled residents (Residents #64, #43 and #537) for Skilled Nursing Facility Advanced Beneficiary Notices (SNF ABN - Form CMS 10055) were notified in writing of the per diem rate of services when they were expected to no longer be covered by Medicare Part A services. The per diem rate was not provided to residents as soon as reasonably possible when the Notice of Medicare Non-Coverage (NOMNC -Form CMS 10123) was issued. The facility census was 86 residents. Review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C-09-20), dated 1/9/09, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure medication carts were locked at all times when not in use resulting in one sampled resident (Resident #15) ingesting medications from medications cards he/she obtained from an unlocked medication cart out of 18 sampled residents. The facility census was 86 residents. The Administrator was notified on 8/2/24 of the past noncompliance which began on 7/20/24. The facility completed an investigation related to the incident. The facility in-serviced all staff who have access to medication carts as well as all facility department heads regarding medication carts being kept locked and ongoing monitoring to ensure medication carts were kept locked when not in use. All medication carts were inspected to ensure locking devices were in good repair. The deficiency was corrected on 7/22/24. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure necessary respiratory care for one sampled resident, (Resident #64), the facility failed to have an order for the Bilevel positive airway pressure (BiPAP a respiratory therapy intervention that delivers an inhale pressure and an exhale pressure to provide a patent airway), settings, cleaning and storage of the BiPap out of 18 sampled residents. The facility census was 86 residents. Review of undated facility policy titled Noninvasive Ventilation showed: -The facility would obtain an order for the use of BiPAP device and settings from the practitioner. -The facility will follow the manufacturer's instruction for use of the machine. -Document use of the machine, resident's tolerance, any skin, respiratory or other changes and response(s). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dental care for teeth in poor repair for one sampled resident (Resident #13) out of 18 sampled residents. The facility census was 86 residents. Record review of the facility Dental Services policy dated 1/20/24 showed: -The facility must provide or obtain from an outside resource routine and emergency dental services to meet the needs of each resident 1. Review of Resident #13's admission Minimum Data Set (MDS - a federally mandated assessment tool required to be completed by facility staff for care planning) dated 11/23/23 showed: -He/she was admitted to the facility on [DATE]. -He/she was cognitively intact. -His/her oral/dental status included obvious or likely cavity or broken natural teeth. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one sampled resident (Resident #1) was free from abuse when on 1/4/24, Resident #2 grabbed Resident #1 by the right arm and twisted and pushed the resident, then on 1/4/24 Resident #2, with known aggressive behavior, again approached Resident #1 and pushed his/her head into the nurse's station desk out of five sampled residents. The facility census was 85 residents. Review of the facilities policy for Abuse, Neglect and Exploitation revised 9/9/22 showed: -Provide health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. -Abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a resident with an appropriate involuntary transfer discharge when they transferred one sampled resident (Resident #2) to the hospital and would not allow him/her to return out of three sampled residents. The facility census was 85 residents. Review of the facility policy Transfer and discharge date d 2021 showed: -The facility will permit each resident to remain in the facility, and not transfer or discharge the resident from the facility except in limited situations when the health and safety of the individual or other residents are endangered. -Facility Initiated Discharge is a transfer or discharge which the resident objects to, did not originate through a resident's verbal or written request, and/or in in alignment with the resident's stated goals of care and preferences. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Preadmission Screen and Resident Review (PASARR is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) Level I and if indicated, Level II was obtained for one sampled resident (Resident #2) having a mental condition, out of three sampled residents. The facility census was 85 residents. Review of facility PASARR policy dated 3/17/04 showed: -A resident discharged /transferred from a Medicaid certified bed in one nursing facility to a Medicaid certified bed in another nursing facility does not require a new PASARR to be completed. -The discharging/transferring nursing facility shall include a copy of the existing PASARR. -The discharging/transferring nursing facility shall notify the local Family Support Division office of the residents transfer. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet all the requirements for a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease), including documented assessments for such an outbreak and a plan to deal with them, in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the resident or their responsible party with a summary of the baseline care plan for four sampled residents (Residents #71, #181, #66 and #53) out of 18 sampled residents. The facility census was 83 residents. Record review of the facility's Baseline care plan policy dated 2022 showed: -Baseline care plans were to be completed within 48 hours of a resident's admission. -The admitting nurse or supervising nurse on duty should collect information and establish resident goals. -A supervising nurse should verify within 48 hours that a baseline care plan was developed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included the resident's Hospice (care that focuses on relieving symptoms and supporting patients with a life expectancy of six months or less) services, needs, goals, outcomes and preferences for one sampled resident (Resident #72) and to include oxygen usage in the comprehensive person-centered care plan for two sampled residents (Resident #53 and #66) out of 18 sampled residents. The facility census was 83 residents. Record review of the facility's Care Plan Comprehensive policy, dated March 2015, showed: -An individualized comprehensive care plan that included measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental and psychosocial well-being. [...]

Inspectors wroteBased on interview and record review, the facility failed to communicate with Hospice (end of life care) regarding changes in the resident's condition, treatment and services provided by Hospice for five sampled residents (Resident #72, #17, #13, #34, and #53) out of 18 sampled residents. This practice had the potential to affect all residents receiving Hospice services. The facility census was 83 residents. Record review of the facility's Hospice Services Policy, undated, showed: -The facility provided and/or arranged for hospice services in order to protect resident's right to dignified existence, self-determination and communications with and access to persons and services inside and outside the facility. -Hospice care was furnished in the facility through an agreement. -The facility agreed to: [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure staffing information was posted in a prominent place, readily accessible to residents and visitors of the daily resident census, or the number of nursing staff for each shift. This practice had the potential to affect residents and visitors who were inquiring about the facility staffing hours. The facility census was 83 residents. Record review of the facility Nurse Staffing Posting Information dated 2022 showed: -It is the policy of this facility to make nurse staffing information readily available in a readable format to residents and visitors. -The nurse staffing sheet will be posted on a daily basis and will contain the following information: --The facility name. --the current date. --Facility's current resident census. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an Automated External Defibrillator (AED - a machine that helps to re-establish an effective heart rhythm in those experiencing a sudden cardiac arrest (when your heart stops) machine by not insuring the staff was checking to ensure all of the pieces of the AED were in the AED bag. This deficient practice had the potential to affect 27 residents who were a full code (wished to have life saving measures preformed if their heart stopped). The facility census was 83 residents. Record review of the facility's undated Basic Life Support training showed: -Every defibrillator should have two sets of pads (which were placed on the victims chest to deliver electric shocks). -Maintenance sheet. Record review of the facility's policy, Emergency Crash Cart and AED dated 2022 showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the usual body weight of one sampled resident (Resident #5) who had an unplanned significant weight loss of 27 pounds which is 15.5 percent (%) in six weeks, out of 18 sampled residents. The facility census was 83 residents. Record review of the facility's Weight Monitoring policy, undated, showed: -Based on the resident's comprehensive assessment, the facility ensured that all residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrated that it was not possible or resident preference indicated otherwise. -Significant unintended changes in weight may indicate a nutritional problem. --The facility used a synthetic approach to optimize a resident's nutritional status and risk factors by: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to coordinate with the pharmacy to ensure a system of medication records that enables accurate reconciliation and accounting for all controlled medications who were on liquid Morphine (a controlled substance, Scheduled II narcotic under the Controlled Substance Act -regulated by the government, used for pain relief that is highly addictive) for one sampled resident (Resident #72) and one supplemental resident (Resident #27) out of 18 sampled residents and 17 supplemental residents. The facility census was 83 residents. Record review of the facility's policy, Narcotic Count, dated March 2015 showed: -The purpose was to complete a physical inventory of narcotics at each shift change to identify discrepancies. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain Drug Regimen Review (DRR) reports and to ensure the reports were acted upon for three sampled residents (Residents #7, #51 and #63) out of six residents sampled for medication review, out of 18 total sampled residents. The facility census was 83 residents. Record review of the facility's DRR policy dated 2022 showed: -The pharmacist was responsible for reviewing the medications of all residents at least monthly. -Each resident's medications were reviewed in order to prevent, identify, report and resolve medication-related problems, medication errors or other irregularities. -The pharmacist was responsible for documenting that each DRR was completed and verbally communicating any irregularities to the attending physician, Director of Nursing (DON) and/or staff of any urgent needs. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' prescribed medications were securely locked in a medication cart when not within sight of a Nurse or Certified Medication Technician (CMT); to ensure the narcotic medication count was correct; to dispose of medications for residents who were no longer in the facility, and to ensure the medication refrigerator was within the correct temperature range of 36 degrees Fahrenheit (F) to 46 degrees F. The facility census was 83 residents. Record review of the facility's policy dated [DATE], Narcotic Count, showed: -Narcotic records were reconciled by a physical count of the remaining narcotic supply at each shift change by the incoming and outgoing Nurse. -One prescription for a controlled substance was entered on one individual narcotic sheet. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately document the administration of as needed pain medication for two sampled residents (Residents #20 and #46) out of two residents sampled for pain, and to complete and/or document treatments for one sampled resident (Resident #42) who had stage III pressure ulcers (full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia), out of a total of 18 sampled residents. The facility census was 81 residents. Record review of the facility policy titled Medication, Administration Guidelines dated March 2015 showed: -The person administering the medication must chart medications immediately following the administration. -The date, time administered and dosage must be documented when administering the medication. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate labeling to facilitate consideration of precautions and safe administration, of medications by not ensuring three vials of vaccines had open dates affecting all residents needing vaccines and medications that had been prescribed by a physician that had been opened had an opened date written on them. The facility census was 81 residents Record review of the facility's policy, Storage of Medications, dated [DATE] showed: -Medications must be stored in the container in which they were received. -No discontinued, outdated or deteriorated drugs may be retained for use. -All such drugs must be returned to issuing Pharmacy or destroyed in accordance with established guidelines. 1. Observation on [DATE] at 9:46 A.M., of the nurse's medication room refrigerator at the main nurse's station showed: [...]

Inspectors wroteBased on observation and interview, the facility failed to separate dented cans of foodstuffs; to maintain safe, sanitary, and easily cleanable food preparation equipment and serving utensils; to use color-coded cutting boards to avoid food safety hazards; and to ensure foreign particles could not get into the food while being prepared. These deficient practices potentially affected all residents who ate food from the kitchen. The skilled nursing facility census was 81 residents with a licensed capacity for 90. 1. Observations during the initial kitchen inspection on 2/10/19 between 9:03 A.M. and 11:51 A.M. showed the following: -A 106 ounce can of diced pears that was dented at the top and bottom edges was on the can dispenser rack with normal stock. -The range hood above the stove had an accumulation of dust on the filters, their handles, and the wire guards around the lights. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide Restorative Aide (RA) services as ordered for one sampled resident (Resident #5) out of 18 sampled residents. The facility census was 81 residents. Record review of the facility's Restorative Nursing (RNA) Program policy dated May 2006, showed: -The restorative nursing program was an integral part of maximizing the daily restorative care process for the residents. -The RNA program was a part of the logical step-down process in resident care. -A proactive approach was necessary to prevent future negative outcomes. -Clear lines of authority, expectations, and responsibilities were necessary for implementation of the RNA program. -Restorative services were to be made available seven days a week, per residents' assessed needs. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly contain waste in nearby close-lidded dumpsters to prevent the harboring and/or feeding of pests. This deficient practice potentially affected all residents who ate food from the kitchen. The facility census was 81 residents with a licensed capacity for 90. 1. Observation outside the facility at the north end of the parking lot on 2/10/20 at 12:55 P.M. showed the left of two dumpsters had its right lid propped open. Observation during the outer perimeter inspection with another corporate facility's Maintenance Director on 2/10/20 at 1:49 P.M. showed the right of two dumpsters had its left lid propped open. Observation on 2/10/20 at 3:59 P.M. showed the right of two dumpsters had its left lid propped open and a cat was lingering between the two dumpsters. Observation on 2/11/20 at 8:33 A.M. [...]

Inspectors wroteBased on interview and record review, the facility failed to offer or document the refusal of the pneumonia (lung inflammation caused by infection) vaccine(s) for three sampled residents (Residents #32, #13, and #179) out of five residents sampled for immunizations out of a total of 18 sampled residents. The facility census was 81 residents. Record review of the facility's undated policy titled Immunization Recommendations for Residents of Long-Term Care Facilities showed: -The pneumonia vaccine(s) would be administered to residents age [AGE] and older unless contraindicated if they had not received either pneumonia vaccine or had an unknown vaccine history. [...]