Aspire Senior Living Platte City

Inspectors wroteBased on interview and record review the facility failed to ensure there was a safe and effective medication system in place when ordering and medication administration to ensure no significant medication errors, when one resident, Resident #1, received 28 doses of Torpenz 10mg tablet, a medication used to treat breast cancer, that was not ordered by the physician. This effected one of three sampled residents. The facility census was 66. On 04/16/26, the Administrator was notified of the past noncompliance which began on 03/18/26. On 04/16/26, the facility administrator was notified of the incident, an investigation immediately began and corrective actions were implemented to include education provided to licensed staff on 04/16/26 and 04/17/26. The education included inputting orders in the medical record. Check and verify the order is correct. [...]

Inspectors wroteBased on interview and record review, the facility failed to act promptly and consider concerns and recommendations of the resident council members when the facility did not communicate back to the resident council with regard to concerns brought forward by the resident council, as reported by twelve of twelve residents who participated in a group interview. The facility additionally did not maintain documentation of resident council concerns or provide follow to the resident council with resolutions or follow up actions. The facility census was 65. Review of facility policy, Resident Grievances, dated April 2006, showed: -The resident has the right to exercise his or her rights as a resident of the facility and as a citizen of the United States. The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility exercising his or her rights. [...]

Inspectors wrote7. Review of facility policy, personal property, undated, showed: -Resident's personal belongings and clothing shall be inventoried and documented upon admission and as such items were replenished. Residents and/or families are requested to assist in documenting and maintaining inventory of Resident's personal property; -The facility will promptly investigate any complaints of misappropriation or mistreatment of resident property. Review of facility policy, Safe and Homelike Environment, dated 2021, showed the facility exercises reasonable care for the protection of the resident's property from loss or theft. Review of Resident council minutes, March 2025-May 2025, showed: -On 3/24/25 there was concerns voiced from two residents regarding missing clothing and notes regarding clothes being misplaced with other residents. [...]

Inspectors wrote3. Review of Resident #13's Quarterly MDS, dated [DATE], showed: - Cognitive skills intact; - Upper and lower extremities impaired on both sides; - Dependent on the assistance of staff for eating, toilet use, dressing, personal hygiene and transfers; - Had a urinary catheter; - Had a colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon); - Diagnoses included anxiety, depression, post traumatic stress disorder (PTSD), and quadriplegia (paralysis of all four limbs). Review of the resident's face sheet showed the resident was a full code. Review of the resident's care plan, revised 5/29/25, showed the care plan did not address the resident's code status. Review of the resident's Physician Order Sheet (POS), June, 2025 showed an order for full code with a date of 5/30/25. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to discard expired medications and biologicals stored in the medication cart and the medication room, failed to date an opened vial of insulin for one resident (Resident #16), and failed to ensure refrigerator and freezer temperatures were documented in medication rooms. Additionally, the facility failed to ensure medication packaging (bubble pack) was not punctured which affected two residents (Resident #13 and #50). Staff failed to ensure medication carts were locked when not in use and failed to ensure non-medication/medical items including vape pens, a resident's pocket knife, and loose change were not stored in the medication cart. Lastly, the facility failed to store eye drops appropriately for one resident (Resident #45). The sample size was 16 residents. The facility census was 65. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to store, prepare and serve food in accordance with professional standards of food service safety when staff failed to date, label, and store food items correctly, failed to maintain environmental and cleanliness standards for the kitchen, failed to adhere to proper hygiene standards for hairnets and handwashing, failed to perform temperature checks on food items prior to serving to residents, failed to adhere to proper portion control when serving meals, failed to properly monitor and document sanitizer concentration levels for the dishwashing machine, and failed to follow approved recipe cards for meals prepared. This effected all the residents at the facility. The facility census was 65. Review of facility policy, Employee Hygiene, dated 1/30/24, showed: - Employees must keep hands, arms, fingernails clean; [...]

Inspectors wrote4. Review of the facility's policy for Indwelling Urinary Catheter Care, revised 1/24/25 showed: - The purpose is to establish safe and effective guidelines for the care and maintenance of residents with indwelling urinary catheter, preventing infections, ensuring comfort, and promoting dignity; - The policy did not address how to empty the drainage bag. Review of the facility's undated policy for Hand Hygiene, showed: - Hand washing will be regarded by the facility as the single most important means of preventing the spread of infection; - Hands should be washed for at least twenty seconds using soap and water under the following conditions: whenever hands are visibly dirty; before having direct contact with a resident; after having direct contact with a resident; before performing invasive procedures;before performing invasive procedures; before preparing or handling medications; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents and/or resident representatives were provided education regarding the benefits and/or risks of immunizations prior to receiving the influenza or pneumococcal vaccines and document the education was provided. This affected five out of sixteen sampled residents (Resident #53, #13, #64, #55, and #33). Facility census was 65. Review of facility policy, Influenza prevention and management, undated, showed: -the facility will provide education prior to the start of each flu season as to the benefits of getting a flu shot. Informed consent or refusal of the vaccine will be expressed in writing using facility -approved forms (residents). Review of facility policy, influenza and pneumococcal immunizations-residents, undated, showed: -Purpose: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two out of sixteen sampled residents reviewed for unnecessary medications, (Resident #53, #57) and/or their representative were informed of the risks and benefits of a physician ordered antipsychotic medication. This failure prevented the resident and/or their representative from knowing the risks and the benefits of using psychotropic medications. The facility census was 65. Review of facility policy, Use of psychotropic medications, dated 2022, showed residents and/or representatives shall be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments/non-pharmacological interventions. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff provided the Notice of Medicare Non-Coverage (NOMNC) to the resident or resident's representative when changes in coverage are made to items and services covered by Medicare. The facility provided verbal notification over the phone, however no written notice was mailed on the same date and placed in the beneficiary's medical file. Additionally, the facility failed to include the name of the staff person initiating the contact, the time of the phone call, and the telephone number called on the NOMNC form and failed to provide the notice two days preceding the end of covered services for two residents sampled for beneficiary notifications (Resident #172 and Resident #29). The facility census was 65. Review of facility policy, transfer and discharge (including against medical advice), dated 2021, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff provided a written notice of transfer or discharge and bed hold which contained all of the required components for three of the 16 sampled residents (Resident #1, #13, and #33). The facility census was 65. Review of the facility's policy for Transfer and Discharge, dated 2021, showed: - It is the policy of this facility to 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; - The facility may initiate transfers or discharges in the following limited circumstances: the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate treatment and services to maintain the strength and mobility for one resident (Resident #67) of 16 sampled residents. Facility census was 65. Review of the facility policy, Restorative Nursing Documentation, undated, showed: - The facility maintains complete, accurate, and organized documentation of restorative treatments and the response to those treatments; - The need for restorative nursing services will be documented in the medical record and indicated in the resident's care plan; - It will contain the problem, need or strength that is being addressed along with a measurable goal with target date; - It will contain specific interventions/treatments to be provided and the frequency and duration; [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not complete showers for three of the 16 sampled residents, (Resident #13, #46, and #64). The facility census was 65. Review of the facility's policy for Resident Rights, dated 2022, showed: - The resident has the right to a dignified existence, self-determination, and communication with and assess to persons and services inside and outside the facility; - The resident has the right to be informed of, and participate in his/her treatment. 1. Review of Resident #13's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/2/25 showed: - Cognitive skills intact; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status when the facility did not timely identify, treat, and notify the primary physician of severe weight loss for two of 16 sampled residents (Resident #64 and #67). The facility census was 65. Review of facility policy, Weight Monitoring, undated, showed: - The newly recorded resident weight should be compared to the previous recorded weight. A significant change in weight is defined as: 5% change in 30 days, 7.5% change in 90 days, 10% change in 180 days; - The physician should be informed of a significant change in weight and may order nutritional interventions; - The physician should be encouraged to document the diagnosis or clinical conditions that may be contributing to the weight loss; [...]

Inspectors wroteRefer to Event ID U31013 for additional information. Based on observation, interview, and record review, the facility failed to ensure two residents (Resident #3 and #2) were treated with dignity and respect when staff members were unnecessarily rough while providing care. This deficient practice affected two of 6 sampled residents. The facility census was 73.

Inspectors wroteRefer to Event ID U31013 for additional information. This deficiency is uncorrected. For previous examples, see the Statement of Deficiencies dated 03/03/2025. Based on interview and record review, the facility failed to report an injury of unknown origin to the Department of Health and Senior Services (DHSS) when Resident #1 sustained an open fracture (a bone break with an opening to the skin) to his/her right femur (upper leg bone). The Director of Nursing (DON) assessed the resident and did not report the injury of unknown origin to DHSS and did not immediately report to the Administrator. This deficient practice affected one of one sampled residents. The facility census was 73.

Inspectors wroteRefer to Event ID U31013 for further information. This deficiency is uncorrected. For previous examples, see the Statement of Deficiencies dated 03/03/2025. Based on interview and record review, the facility failed to initiate an investigation into an injury of unknown origin when Resident #1 sustained an open fracture (a bone break with a skin opening) to his/her right femur (upper leg bone). The Director of Nursing (DON) assessed the resident and did not initiate an investigation to determine the cause of the injury. This deficient practice affected one of one sampled residents. The facility census was 73.

Inspectors wroteBased on interview and record review the facility failed to protect one resident (Resident #4) of 6 sampled residents, right to be free from verbal and physical abuse when Certified Medication Technician (CMT) A called the resident derogatory names based on his/her body type and abilities and roughly pushed the resident's wheelchair forward. The facility census was 66. Review of the facility policy titled, Abuse Prevention Program, dated 1/20/25 showed: -It is the policy of this facility to provide protections for the health, welfare and rights of each resident; -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment resulting in physical harm, pain, or mental anguish. Instance of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. [...]

Inspectors wroteA revisit was completed and the facility was found to have continued non-compliance. Refer to Event ID U31012 for federal and state deficiencies cited as a result of this complaint investigation. Based on interview and record review, the facility failed to report an injury of unknown origin, when the facility staff became aware on 2/27/25 that one resident (Resident #1) had a right leg femur fracture. The facility census was 67.

Inspectors wroteRefer to Event ID U31012 Based on interview and record review, the facility failed to complete a thorough investigation when one resident (Resident #1) sustained a femur fracture of unknown origin and failed to maintain documentation that an alleged violation was thoroughly investigated. The facility census was 67.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two residents (Resident #3 and #2) were treated with dignity and respect when staff members were unnecessarily rough while providing care. This deficient practice affected two of 6 sampled residents. The facility census was 73. Review of the facility policy titled Resident Rights, dated 1/30/24, showed the facility staff will treat the resident with respect and dignity. Review of the facility policy titled Perineal Care, dated 1/20/25, showed: - The purpose of the policy was to ensure the residents receive safe and respectful perineal care; - The staff are to uphold the resident's dignity with professional standard in long-term care; - All residents who require assistance with perineal care will be provided with appropriate and person-centered care that promotes their comfort and dignity. 1. [...]

Inspectors wroteBased on interviews and record review, the facility failed to protect Resident #2's right to be free from sexual abuse by Resident #1, when Resident #1 was observed by staff sitting next to Resident #2, with his/her hand down the front of Resident #2's pants. The facility census was 63. Review of the facility's undated Abuse Prevention Program policy showed: -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment resulting in physical harm, pain, or mental anguish. Instance of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology; -Sexual abuse is defined as non-consensual sexual contact of any type with a resident; [...]

Inspectors wroteBased on interview and record review, the facility failed to report an injury of unknown origin, when the facility staff became aware on 2/27/25 that one resident (Resident #1) had a right leg femur fracture. The facility census was 67. Review of facility policy, Abuse, Neglect, and Exploitation, revised 1/17/25, showed: -Reporting of all alleged violations to the administrator, state agency, adult protective services, and to all other required agencies within specified time frames: -Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or -Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a thorough investigation when one resident (Resident #1) sustained a femur fracture of unknown origin and failed to maintain documentation that an alleged violation was thoroughly investigated. The facility census was 67. Review of facility policy, Abuse, Neglect, and Exploitation, revised 1/17/25, showed: -Possible indicators of abuse included: physical injury of a resident, of unknown source; -An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. -Written procedures for investigations include: -Identifying staff responsible for the investigation; -Exercising caution in handling evidence that could be used in a criminal investigation; -Investigating different types of alleged violations; [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and ensure two sampled resident's (Resident #1 and #2) code status was correct at the time of admission and carried out in accordance with the guardian's directive to staff. Resident #1's guardian directed Registered Nurse (RN) A upon admission on [DATE] and to RN B on [DATE] to change the resident's code status to Do Not Resuscitate (DNR). On [DATE], the resident stopped spontaneous respirations and pulse and facility staff initiated cardiopulmonary resuscitation (CPR). Emergency Medical Services (EMS) were called to the facility and took over CPR from facility staff. CPR was performed for one hour and 13 minutes. The resident was declared deceased at the facility on [DATE] at 2:16 A.M. [...]

Inspectors wroteBased on observation and interviews, the facility failed to ensure staff served food to the residents that was palatable, attractive, and served at a safe and appetizing temperature to the residents when hot food was not served at an appetizing temperature to seven of the 17 sampled residents (Resident #8, #2, #58, #27, #56, #55, and #212). The facility census was 66. Review of facility policy, food and drink, dated 1/30/24, showed: -Food prepared by methods that provides nutritive value, flavor and appearance; -Food and drink that is palatable, attractive, and served at a safe and appetizing temperature Review of food safety policy, dated 1/30/24, showed: -Facility must store, prepare, distribute, and serve food in accordance with professional standards for food safety. [...]

Inspectors wroteBased on observation, record review, and interviews the facility failed to store, prepare, and serve food in accordance with professional standards of food service safety when staff with facial hair failed to wear beard coverings, failed to wash hands, failed to date and label all foods, failed to have thermometers in refrigerator and freezer, and failed to maintain a clean and sanitary kitchen. This had the potential to impact all residents in the facility. The facility census was 66 residents. Review of facility policy, food and drink, undated, showed: -Purpose: ensure that the nutritive value of food is not compromised or destroyed because of prolonged: -Food storage, light, and air exposure; -Cooking of foods in a large volume of water or; -Holding on a steam table. -Procedure: [...]

Inspectors wroteBased on Based on observations, interviews and record review, the facility failed to treat each resident with respect and dignity and failed to provide care for each resident in a manner and in an environment that promoted enhancement in their quality of life when staff failed to knock on resident doors prior to entering their room and failed to announce themselves to (Resident #2 and #8), Staff left the bedroom door to the hallway open while providing peri-care to one resident (Resident #35). Additionally, staff failed to answer one resident's call light in timely manner resulting in that resident being incontinent of urine (Resident #21). This affected four residents out of the 17 sampled residents. The facility census was 66. Review of facility policy, Resident Rights, dated 1/30/24, showed: [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to create an environment respectful of the rights of a resident to make choices about aspects of his/her life that are significant to them, when the facility failed to allow two out of seventeen sampled residents to go outside unsupervised (Resident #45 and #212). The facility census was 66. Review of the facility's Resident Rights policy, dated 1/30/24., showed: -Residents do not leave their individual personalities or basic human rights behind when they move to a long-term care facility. The facility will 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 and recognizes each resident's individuality. [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain a surety bond sufficient to ensure the protection of resident funds. The facility census was . Review of the facility maintained Resident Trust Bank Statements for the period 05/2023 through 05/2024, showed an average monthly balance of $27,000.00. Review on 05/07/24, of the Department of Health and Senior Services approved bond list showed the facility had a $1,000.00 approved bond, making the bond insufficient by $22,000.00. During an interview on 05/07/24 at 10:42 A.M., the Business Office Manager said the facility had changed ownership recently and was unaware the bond had not been reassessed since the new company had taken control. During an interview on 05/07/24 at 3:44 P.M., the Business Office Manager said she would expect the bond to be sufficient to cover the resident funds.

Inspectors wroteBased on observation and interview, the facility failed to protect the resident rights when the facility did not provide accessible information regarding the State Long Term Care Ombudsman program and the State Survey Agency in a location that was readily available and could be read by residents in the facility without assistance. The facility census was 66. Review of facility policy, resident rights, undated, showed: -The resident has the right to receive a list of the names, addresses (mail and email) and telephone numbers of all pertinent state regulatory and informational agencies, resident advocacy groups such as the State Survey Agency, the State licensure office, the State Long-Term Care ombudsman program, the protection and advocacy agency, adult protective services, the local contact agency for information about returning to the community and the Medicaid Fraud Control Unit. [...]

Inspectors wroteBased on interviews and record review, the facility failed to clarify the code status (whether the resident wished to have cardio-pulmonary resuscitation- CPR) of two of the 17 sampled residents, (Resident #45 and #214), and failed to ensure Resident #16's Durable Power of Attorney (DPOA) for Health Care Decisions was invoked (activated by verifying incapacity of the resident to make decisions) by two physicians. The facility census was 66. Review of the facility's policy for living will/advance directives/life-sustaining treatment orders, dated [DATE], showed, in part: - The purpose is to ensure resident rights are protected when Advance Directives have been executed: [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure they maintained a safe, clean, comfortable homelike environment for the residents when staff did not keep all areas of the facility clean and safe; and failed to maintain comfortable temperatures in the common areas of the building between 71 and 81 degrees Fahrenheit (F). Additionally, the facility failed to ensure they provided a sufficient amount of bed linens, towels and wash cloths. The facility census was 66. Review of the facility policy Cleaning Resident Rooms dated 1/30/24 showed: -Ensure rooms are clean and sanitary. The facility did not provide a policy on cleaning hallways, general areas or common areas of the facility. The facility did not provide a policy on Homelike Environment. The facility did not provide a policy for the amount of linens the facility should have on hand. 1. [...]

Inspectors wroteBased on interviews and observation, the facility failed to ensure residents knew how to file a grievance. This deficient practice had the potential to affect any resident wanting to file a grievance. The facility census was 66. Review of facility policy, resident rights, undated, showed a resident has the right to voice grievances to this facility or other agency concerning treatment, care, behavior of staff and/or other residents as well as other concerns about his/her stay without discrimination or reprisal. The resident has the right to information on how to file a grievance or complaint as well as to the prompt resolution of grievances. 1. During a group meeting on 5/7/24 at 1:32 P.M., thirteen of thirteen residents said that they did not know how to file a formal grievance or who the grievance officer in the facility was. [...]

Inspectors wroteBased on record review and interview, the facility staff failed to check the Certified Nurse Assistant (CNA) Registry for all staff to ensure they did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse/neglect). This affected three of ten sampled staff (Certified Medication Technician A, Dietary Aide C, and Licensed Practical Nurse C). The facility census was 66. Review of facility Policy, Abuse and Neglect, dated 1/30/24, showed: -Employee background checks and employment history collection will be done before hire. The facility will not knowingly employ any individual who had been found guilty of abusing, neglecting, exploiting, misappropriating, or mistreating individuals. -The abuse prevention program provides polices and procedures that govern, as a minimum: -Conducting employee background checks. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff provided a written notice of transfer or discharge to residents or their responsible parties that included the reason for the transfer, in writing and in a language they understood. The notice should have included the effective date of discharge or transfer, the location to which the resident would be transferred or discharged , and information regarding the resident's appeal rights, including how to file an appeal or obtain assistance in completing and submitting it. The facility also failed to notify the State Long-Term Care Ombudsman of the transfers and discharges. This affected two of 17 sampled residents, (Resident #14 and #27). The facility census was 66. The facility did not provide a policy for transfer/discharge of a resident. 1. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure staff informed the residents and their family/legal representatives of the bed hold policy at the time of the transfer/discharge to the hospital for two of 17 sampled residents, (Resident #14 and #27). The facility census was 66. The facility did not provide a bed hold policy. 1. Review of Resident #27's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/8/24 showed: - cognitive skills moderately impaired; - upper and lower extremities impaired on one side; - dependent on staff for toilet use and transfers; - frequently incontinent of urine; - always incontinent of bowel; [...]

Inspectors wroteBased on observation, interview's and record review, the facility failed to complete a Minimum Data Set (MDS) a federally mandated assessment completed by the facility staff within the required time frames, upon the resident's admission for 3 of 17 sampled resident's (Resident #214, #216, and #212). The facility census was 66. The facility did not provide a policy regarding comprehensive assessments. Review of facility policy, Medically Related Social Services, dated 1/30/24, showed: -Facility must provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. -Social services services may include identifying and seeking ways to support resident's individual needs through the assessment and care planning process. 1. Review of Resident #214's Face Sheet, dated 5/7/24, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans, to address the specific needs of the residents, for three of 16 sampled residents (Residents #162, #45, #216, and #214). The census was 66. Review of the facility provided policy, Comprehensive Care Plan, dated 1/30/24 showed: -Each resident will have a person centered comprehensive care plan developed and implemented to meet his/her preferences and goals and address the resident's nursing medical, physical, mental and psychosocial needs identified in the comprehensive assessment. -The comprehensive care plan will be developed within seven days after the completion of the comprehensive assessment. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADL's) received the necessary services to maintain good personal hygiene when staff did not provide complete perineal care which affected three of the 17 sampled residents, (Residents #9, # 35 and #57), as well as failed to ensure showers were completed for four Residents #2, #45, #50 and #162, and additionally the staff failed to reposition Resident #57 who was dependent upon staff for assistance with repositioning. The facility census was 66. Review of the facility's undated policy for shower/tub bath, showed, in part: - The purpose is to promote cleanliness and comfort, relax the resident, stimulate circulation, and facilitate observation of the resident's skin condition. . [...]

Inspectors wroteBased on observations, interviews and record review, the facility staff failed to assure staff used proper techniques to reduce the possibility of accidents and injuries during the use of a gait belt transfer (a safety device and mobility aid used to provide assistance during transfers, ambulation or repositioning) for one of 17 sampled residents, (Resident #9) and properly transfer two residents (Residents #21 and #4 ) in a manner to prevent accidents. The facility census was 66. Review of the facility provided policy, Accidents, dated 1/30/24 showed: -The facility must ensure that each resident receives adequate supervision and use of assistance devices to prevent accidents. -All staff will commit to and promote safety. Review of the facility policy, Safe Resident Handling/Transfers, dated 2021 showed: [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure staff maintained the hydration status for three of the 17 sampled residents, (Resident #2, #8 and #56), and all residents who attended the group meeting, when staff did not pass fresh ice water to the residents. The facility census was 66. Review of the facility's policy for assisted nutrition and hydration, dated 1/30/24 showed, in part: - The purpose is to ensure each resident maintains, to the extent possible, acceptable parameters of nutritional and hydration status and the facility provides nutritional and hydration care and services to each resident, consistent with the resident's comprehensive assessment; - Based on a resident's comprehensive assessment, the facility must ensure that each resident is offered sufficient fluid intake to maintain proper hydration and health. 1. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to assure staff provided proper respiratory care for residents, when staff failed to ensure the oxygen concentrator had humidified sterile water which affected two of 17 sampled residents, (Resident #7 and #56), failed to properly clean the oxygen concentrator filter for Resident #56, and additionally failed to date oxygen/ nebulizer tubing for Resident #7 and #56. The facility census was 66. The facility did not provide a policy for respiratory care. 1. Review of Resident #7's Annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/1/24 showed: - Cognitive skills moderately impaired; - Upper extremities impaired on both sides; [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to assess residents for risk of entrapment from bed rails prior to installation and failed to ensure the bed's dimensions were appropriate for the residents size and weight, failed to complete side rail assessments, and failed to obtain a physician's order prior to installation for five of seventeen sampled residents (Resident #45, #216, #14, #1, and #162). The facility census was 66. Facility did not provide a policy on side rails. Review of facility policy, Bed and Bed Rail Maintenance to Reduce/Prevent Entrapment, dated [DATE], showed: -Ensure that facility beds meet FDA guidance to reduce/prevent resident entrapment. The facility will only utilize beds and bed rails that meet this guidance. [...]

Inspectors wroteBased on observations, interviews, record review, the facility failed to provide sufficient nursing staff to meet the resident needs for six of the 17 residents. When staff failed to timely answer resident call lights, failed to provide assistance for one resident to use the bathroom (Resident #21 ), failed to reposition one resident (Resident #57), failed to provide feeding assistance to one resident (Resident #216), failed to have nursing staff available to speak with family (Resident #216), and failed to provide showers twice a week for three residents (Resident #50, #39, #45) of the 17 sampled residents. The facility census was 66. The facility did not provide a policy regarding staffing. Review of facility policy, resident rights, dated 1/3/24, showed: [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure staff administered medications with a medication rate of less than 5% when facility staff made six medication errors out of 25 opportunities and a medication error rate of 24%, . This affected six of the 17 sampled residents, (Resident #6, #34, #39, #47, #51 and #56). The facility census was 66. Review of the facility's undated policy for medication administration, showed, in part: - Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection; - Administer medications as ordered and in accordance with manufacturer specifications. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free of significant medication errors when staff failed to prime insulin pens for two residents resulting in three significant medication errors out of the 25 sampled medications. The facility census was 66. Review of the facility's undated policy for medication administration, showed: - Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection; - Administer medications as ordered in accordance with manufacturer specifications. Review of Novo Nordisk (manufacturer of Flex Pen) December 2022 fact sheet showed: -Before each injection, prime your pen by performing an airshot. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staffing was sufficient to serve residents their meals in a timely manner. This affected three of the 17 sampled residents (Resident #216, #16, and #8). The facility census was 66. Review of facility policy, assistance with meals, dated March 2016, showed: -Residents will receive assistance with meals in a manner that meets the individual needs of each resident. -Nursing staff and or feeding assistants will serve resident trays and will help residents who require assistance with eating. -Nursing staff will remove food trays from food cart and deliver the trays to each resident's room. -Nursing staff and/or feeding assistants will feed those residents needing full assistance. -Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity. 1. [...]

Inspectors wroteBased on interviews and record review, the facility failed to have a Quality Assurance and performance Improvement (QAPI) plan and failed to have a plan that contained all required elements. This affected all the residents in the facility. The facility census was 66. The facility did not provide a policy for QAPI. During an interview on 5/9/24 at 9:06 A.M., the Administrator said: - She started as the Administrator on 3/14/24; - At this time she was unable to locate any policies and procedures for QAPI; - They have only had one QAPI meeting. Members who attended were all the department heads, the staffing coordinator and the dietary/housekeeping supervisor; - She talked to the Medical Director monthly.

Inspectors wroteBased on interviews and record review, the facility failed to ensure they developed and implemented appropriate plans of action to correct identified quality deficiencies as part of their Quality Assessment and Assurance (QAA) committee. This affected all the residents in the facility. The facility census was 66. The facility did not provide a policy in regards to their QAA process or committee. The facility was unable to provide record of the the QAA and Quality Assurance/Performance Improvement (QAPI) plan. During an interview on 5/9/24 at 9:06 A.M., the Administrator said: - She started as the Administrator on 3/1424; - She was unable to locate the policy and procedures for QAPI; - They have only had one QAPI meeting. Members who attended were all the department heads plus the staffing coordinator and the dietary/housekeeping supervisor. She talks to the Medical Director monthly.

Inspectors wroteBased on observation, interview and record review, the facility failed to have an Infection Prevention program to include policies and procedures for infection control. Additionally, the facility staff failed to follow acceptable infection control practices to prevent the spread of infection for three residents (Resident #34, #9 and #35) when staff failed to ensure administered medications did not come in contact with unclean surfaces for one resident (Resident #34), failed to wash hands between areas of clean and dirty when providing personal care, failed to clean up bodily fluids from the floor before walking through it and laying a mat over it, for one resident (Resident #9) and touched medications with bare hands for two residents (Resident #34 and #35). The facility census was 66. The facility did not provide a policy on infection prevention and control. 1. [...]

Inspectors wroteBased interview, the facility failed to establish an infection prevention and control program (IPCP) that included an antibiotic stewardship program that addressed antibiotic use protocols and a system to monitor antibiotic use. The facility census was 66. The facility did not provided a policy regarding infection control and prevention. Review of Resident #50 Quarterly Minimum Data Set (MDS:a federally mandated assessment tool completed by facility staff) dated 3/1/24 showed: -Brief Interview of Mental Status (BIMS) of 15, indicated no cognitive deficit. -Dependent for Activities of Daily Living (ADL's: tasks performed in a day to care for oneself) Occasionally Incontinent of bowel and bladder. -Diagnoses of cerebral infarction (loss of blood flow to part of the brain: a stroke), cardiovascular disease (heart disease), muscle spasms. cystitis (urinary tract infection). [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure they maintained documentation to show they provided training to their staff regarding what constitute abuse, neglect, exploitation and misappropriation of resident property, procedures for reporting incidents of abuse, neglect, exploitation, or misappropriation of resident property and dementia management and resident abuse prevention. The facility census was 66. The facility did not provide documentation to show they provided training to all staff on abuse, neglect, exploitation and misappropriation of resident property when requested. During an interview on 5/8/24 at 5:31 A.M., Nurse Aide (NA) A said: -He/She had worked at facility a couple of months; -He/She had not had any abuse and neglect training at the facility; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the nurse aides (NA) had a minimum of 12 hours of in-service education (which included abuse, neglect, and dementia care) per year by not providing documentation of these in-services for three of three randomly selected nurse aides. The facility census was 66. Review of facility policy, Abuse Prevention Program, dated 1/30/24, showed: -Mandated staff training/orientation programs that include such topics as abuse prevention, identification, and reporting of abuse, stress management, dealing with violent behavior, or catastrophic reactions, and dementia management. Facility did not provide documentation of abuse and neglect or dementia education. During an interview on 5/8/24 at 5:31 A.M., NA A said: -He/She had not had any abuse and neglect training; -He/She had not received any dementia care training. [...]

Inspectors wroteBased on interview and closed record review, the facility staff failed to complete a comprehensive discharge summary for one resident (Resident #61) out of three discharged residents. The facility census was 66. The facility did not provide a policy regarding the discharge process. Review of Resident #61 Electronic Medical Record showed: -The resident was admitted to the facility 09/30/2023. - Diagnoses included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident diagnosed with dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) had a personalized plan of care in place to ensure appropriate services to promote the resident's highest level of functioning and psychosocial needs were provided for one resident (Residents #216) out of the seventeen sampled residents. The facility census was 66. The facility did not provide a policy in regards to addressing behaviors or care for residents with dementia. 1. Review of Resident #216's face sheet, dated 5/7/24, showed: -Resident admitted to facility on 4/22/24 -Diagnoses included: neurocognitive disorder with lewy bodies (a type of progressive dementia that leads to decline in thinking, reasoning, and independent function). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff reconciled Schedule II controlled substances (medications with a potential for abuse and dependence) that were stored in the facility's medication cart and the facility's stat safe (emergency drug supply). This effected Resident #1 and Resident #2. The facility census was 59. Review of the facility's Medication Administration policy, dated 2021, showed: -Medications are to be administered in accordance with professional standards of practice; -If a medication is a controlled substance, the narcotic book must be signed; -Correct any discrepancies and report to the nurse manager. Review of the facility's Controlled Substance Administration and Accountability policy, dated 2023, showed: -The facility will have safeguards in place in order to prevent loss and diversion of controlled substances; [...]

Inspectors wroteBased on interviews and record review, the facilty failed to ensure one cognitively impaired resident (Resident #1) was free from sexual abuse by another cognitively impaired resident (Resident #2) when Resident #1 was found in Resident #2's room with the door closed. The door was opened by staff who observed Resident #2 with his/her hand under Resident #1's shirt while resident #2 had his/her pants to his/her ankles, sitting on the side of the bed and fondling his/her genitals. This deficient practice affected one of five sampled resident. The facility census was 59. Review of the facilities undated abuse and neglect policy showed: - Defines sexual abuse as non-consensual sexual contact of any type with a resident. Review of the undated resident rights policy showed each resident has the right to be free from abuse. 1. Review of Resident #1's record showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were within the reach of residents and accessible for use within the residents room for two residents (Resident #24 and #28). The facility also failed to provide all residents with home-like dinnerware during meal service, and failed to give Resident #31 a wheelchair that properly fits him/her, in a timely manner. The facility census was 47. The facility did not provide a policy regarding call light accessibility. The facility does not have a policy pertaining to proper dinnerware. 1. Observation and interviews of the Dining Room on 9/12/22 at 12:10 P.M. showed: -The salad was served out of a styrofoam bowl and dessert was on a paper plate. The salad fork was plastic. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to clarify the status of the advanced directives of two residents (Residents #6 and #35) of 12 sampled residents. The facility census was 47. The facility did not provide a policy on advanced directives. 1. Review of resident #6's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff dated [DATE] showed: -admitted to facility on [DATE] with a Brief Interview for Mental Status (BIMS) of an 8 out of a possible 15. A score of 8 indicates resident is considered to be mildly impaired. -Review of the Annual MDS dated [DATE] resident has a BIMS of 6 equals very severe impairment. Review of resident #6's medical record on [DATE] at 2:18 P.M. showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a care plan with the resident's specific conditions, needs, and risks to provide effective person centered care for two residents ( Resident #23 and Resident #24) out of the 12 sampled residents. The facility census was 47. Facility's care plan comprehensive policy provided from their nursing guideline manual states: - Purpose: An individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well -being. - Guidelines: The interdisciplinary care plan team with input from the resident, family, and or legal representative, will develop and maintain a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing program of activities designed to meet the resident's interests for seven residents (Resident #6 #39, #38, #23, #31, #35 and #24) out of 12 sampled residents. The facility census was 47. Review of Resident Activities Policy on 9/15/22 at 1:52 P.M. showed: -An activity program is planned for each resident as part of their total resident care by the Activity Director, in cooperation with Nursing and with Physician approval. Residents shall be encouraged, but not forced, to participate in activities of choice. -An individualized program will be implemented for residents unable to participate in or attend. 1. Review of Resident #6's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by staff, dated 9/12/22 showed: [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to prepare and serve foods that were attractive and palatable to residents. The facility census was 47. Review of Test Meals policy dated April 2011 states: The test meals will be tested at point of delivery to residents. 1. The meal tested should vary (All meals should be examined.). 2. The destination of the tray will also vary. 3. The diets that are tested will be regular and pureed. 4. The test tray will be the last tray on the cart and is tested after all other trays have been served. 5. The Dining Services Manager is responsible for these guidelines. 6. Hot foods should be delivered to the resident at least 120 degrees Fahrenheit (F). 7. Cold foods should be delivered to the resident at 40 degrees F or below. Review for Refrigerator and Freezer Temperatures policy dated April 2011 states: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to issue a written discharge notice to two residents (Residents #39 and #38). The facility census was 46. The facility did not provide a policy regarding discharge notices. 1. Review of Resident #39's admission Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 7/29/22, showed: -The resident is able to make self understood and understand others. -The resident scored 15 on the Brief Interview for Mental Status (BIMS), a structured evaluation aimed at evaluating aspects of cognition in elderly patients. This indicates the resident is cognitively intact. [...]

Inspectors wroteBased on interview and record review, the facility failed to inform resident's and their family/legal representatives of the bed hold policy at the time of transfer/discharge to the hospital for two residents. (Residents #39 and #38). The facility census was 46. Review of the facility Bed Hold Policy showed: -The facility will notify all residents and/or their representative of the bed hold guidelines. This notification shall be given 1. upon admission the the facility, 2. at the time of transfer to the hospital or leave, and 3. at the time of non-covered therapeutic leave. 1. Review of Resident #39's admission Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 7/29/22, showed: -The resident is able to make self understood and understand others. [...]

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 good personal hygiene for two residents (Resident #23 and #24) out of 12 sampled residents. The facility census was 46. Review of the facility's undated Activities of Daily Living policy, showed: -It is the policy of this facility to specify the responsibility to create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring all staff, across all shifts and departments, understand the principles of the quality of life, and honor and support these principles for each resident; and that the care and services provided are person centered and honor and support each resident's preferences, choices, values, and beliefs. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, or psychosocial well-being for one residents (Resident #92) when the facility failed to conduct skin assessments and a wound care treatment for Resident #92 upon admission. The facility census was 46. The facility did not provide a policy on skin assessment. The facility did not provide a policy on wound care. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received appropriate treatment and services to maintain or improve mobility when staff did not provide range of motion for two residents or a restorative program for contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) prevention and treatment (Resident #23 and #24). The facility census was 46. Review of the facility Restorative Program policy, dated May 2006, showed: -It is the purpose of this policy to see that each resident receives and the facility provides the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and care plan. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dietary staff served hot foods hot when they did not take temperatures of pureed foods prior to meal service and did not follow their policy to serve food at least 120 degrees Fahrenheit. The facility census was 47. Review of the undated facility policy for Food storage showed 1. Proper labeling and dating of all foods. All foods will be considered as leftovers unless in the original container with an expiration date. Leftovers will be discarded after third (3rd) storage day. 2. All food will be stored in appropriate containers. 3. Resident foods will be stored in a designated specific storage area, unless resident has a personal refrigerator in their room. 4. Resident food storage areas will be identified. Monitoring Temperatures: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a base line care plan (plan for immediate needs within 48 hours of admission that included the minimum healthcare information necessary to properly care for the immediate needs of one residents (Resident #92). The facility census was 46. Review of the facility's policy regarding Care Planning showed: -Purpose: A temporary care plan will be implemented to meet the new resident's needs. -Guidelines: 1. To assure that the resident's immediate care needs are met and maintained, a temporary care plan will be implemented within 24 hours of admission. 2. The interdisciplinary care plan team and/or admitting nurse will review the physician orders and implement a nursing care plan to meet the immediate care needs of the resident. 3. [...]