Aspire Senior Living Roaring River

Inspectors wroteBased on interview and record review, the facility failed to provide care per standards of practice when staff failed to complete monitoring of bowel movements per physician order and facility protocol, failed to update the care plan after a resident required hospitalization/treatment for constipation/impaction, and failed to notify the physician of multiple refusals of medications for one resident (Resident #1). The facility census was 64. [...]

Inspectors wroteBased on interview and record review, the facility failed to send notification in writing to the resident and/or the resident's representative of a transfer or discharge to a hospital, including the statement of appeal rights or the name, address, or the telephone number of the Office of the State Long Term Care Ombudsman (advocate for the resident in nursing facilities) within the transfer and discharge notices and bed-hold policy (the holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) for two residents (Resident #1 and #5); failed to send the notification in writing of a transfer or discharge of a resident from a skilled nursing facility to an assisted living facility for one resident (Resident #75); [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide care per standards of practice when staff failed to ensure weekly skin assessments and wound care was completed and documented for four residents (Resident #30, #49, #2, #6) with skin abrasions, including skin cancer, skin tears, and venous wounds. The facility census was 69. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide care per standards of practice when staff failed to ensure weekly skin assessments and wound assessments were completed and documented for five residents (Resident #40, #53, #11, #61, #25) with pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device). The facility census was 69. [...]

Inspectors wroteBased on interview and record review, facility staff failed to post nursing staff information in a prominent, readily accessible area on a daily basis. The census was 69. Review of the facility records did not show a policy regarding posted nurse staffing. Observation on 02/17/26 at 11:05 A.M., showed a nurse staff hours posting located near the nurses' station next to the dining room window, on the wall at approximately 5 feet high, that showed the following:-Dated 02/12/26 (5 days prior);-Census 70;-Day shift: 2 Registered Nurse (RN)/Licensed Practical Nurse (LPN) = 24 hours, 12 Certified Medication Technician (CMT)/Certified Nurse Aide (CNA) = 123 hours, Total = 147 hours;-No night shift hours were listed. Observation on 02/18/26 at 10:30 A.M., showed a nurse staff hours form located near the nurses' station that showed the following:-Dated 02/18/26;-Census 69;-Day shift: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a process in place for initial and periodic bed rail safety checks, to include measurements of the bed frame and bed rails for risk of entrapment, for two residents (Residents #9, #18). The facility census was 69. Review of the facility policy, dated 09/17/25, titled Bed and Assist Bars Use in Long-Term Care, showed the following:-To ensure safe and appropriate use of bed rails, side rails, and assist bars to prevent falls, entrapment, and injury, while complying with CMS and state regulations;-Bed rails or assist bars may only be installed or used with a physician/ provider order;-Orders must specify: type of device, purpose, frequency of use, and any resident-specific precautions.-Nursing/Therapy staff must perform a risk assessment prior to implementation, considering: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Director of Nursing (DON) worked full time and did not work as the charge nurse when the facility had an average daily occupancy of 60 or more residents. The facility census was 69. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide pharmaceutical services in a manner to ensure the proper storage, destruction, and accountability of medications when the facility did not have a process in place for timely destruction and tracking of the unused medications. A sample of 11 residents' (Resident # 60, #40, #53, #100, #101, #102, #1, #10, #13, #39, #103) medications were located in the medication room waiting to be destroyed. The facility census was 69. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nutritional needs of all residents were met when staff failed to prepare pureed diets per approved recipes and failed to provide the approved serving size for pureed meals. The facility census was 69. Review of the facility policy titled, Pureed, revised 10/01/25, showed the following:-Pureed diet menus follow the foods on the regular menu as closely as possible and differ primarily in consistency;-Use an appropriate recipe;-Always refer to the recipe and spreadsheet for directions. Review of the facility's recipe for pureed beef stew showed the following:-Prepare according to the regular beef stew recipe;-Place the number of servings needed, from the regularly prepared recipe into the food processor;-Blend until smooth and serve two #8 scoops (four ounces (oz) per serving. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to appropriately store and label food items, failed to discard food items when appropriate per labeling, failed to air dry dishes before stacking, and failed to check dishwasher temperatures, all to ensure proper sanitaiton and food handling practices to prevent contamination. The facility census was 69.1. Review of the 2022 Missouri Food Code showed food shall be protected from contamination by storing the food in a clean, dry location and where it is not exposed to splash, dust, or other contamination. Review of the facility policy titled, Food Storage (Dry, Refrigerated, and Frozen), dated 2020, showed the following:-Food shall be stored on shelves in a clean, dry area free from contaminants;-All food items will be labeled. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all resident representatives were notified of regarding changes in condition in a timely manner when staff failed to inform one resident's (Resident #1) representative of a decline in his/her wound until two days after the decline was documented. The facility census was 64. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure staff provided care per standards of practice when staff failed to follow physician orders regarding elevated blood glucose levels and failed to document insulin administration amounts due to elevated blood glucose levels for one resident (Resident #1) of four residents sampled. The facility census was 61. Review of the facility policy entitled Blood Glucose Monitoring, revised 01/13/23, showed the following: -Purpose of the policy was to ensure the effective and accurate monitoring of blood glucose levels for individuals with diabetes or at risk for blood glucose abnormalities; to prevent low or high blood sugar; to guide healthcare professionals, caregivers, and patients in proper blood glucose monitoring practices to ensure safe and effective management of diabetes; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one resident (Resident #35) with routine or emergency dental care when the resident exhibited dental concerns resulting in the having continued dental issued including pain and bleeding and causing the resident to be embarrassed by his/her teeth. A sample of 22 residents was reviewed in a facility with a census of 59. Review of the facility policy titled, Oral Hygiene, dated 03/05/24, showed: -Oral care should be provided to each resident at least twice a day unless indicated differently by a doctor or dentist and more frequently if requested by the resident; -Any acute changes in dental status should be reported to the nurse such as drainage, bleeding, redness in gums, oral lesions, painful when touched, loose or broken teeth, etc. 1. Review of Resident #35's face sheet showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in a manner to protect it from potential contamination when staff failed to store cleaning supplies in a separate area from food; failed to date stored food in refrigerator; failed to keep non-food contact surfaces clean and free of debris; failed to dispose of expired food items; failed to rinse dishes prior to placing them into the sanitizer in the three vat sink and sanitize at the minimum manufacturer's requirements; and failed to control flies in the kitchen. The facility's census was 59. 1. Review of the facility's policy titled, Non-Food Storage, undated, showed chemical and toxic products must be stored in a separate closet, closed cabinet, or outside of the kitchen area. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an effective infection control program for all residents when the facility failed to have a program in place for the prevention of the growth of Legionella bacteria (a bacteria which causes a respiratory disease when breathing in small droplets of water in the air that contain Legionella. It can become a health concern when it grows and spreads in human-made water systems) in the facility water supply or where moist conditions existed. The facility had a census of 59. Review of the Centers for Disease Control and Prevention (CDC) Toolkit for Legionella (also titled Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings), dated [DATE], showed healthcare facilities need to actively identify and manage hazardous conditions that support growth and spread of Legionella by: [...]

Inspectors wroteBased on interview and record review, the facility failed implement an antibiotic stewardship program when staff failed to adequately track eight residents currently on antibiotics for various infections in the facility by not completing a current and ongoing antibiotic log of residents with active infections, this failure could potentially place all residents at risk of infection. The facility census was 59. Review of the facility policy titled, Infection Control, General, revised on 02/18/24, showed: -It is the policy of the facility to ensure that the infection control program is designed to prevent, identify, report, investigate, and control the spread of infections and communicable disease for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement, provide a safe, sanitary, and comfortable environment; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to control the fly population when multiple flies were present in and around eight residents (Residents #54, #52, #41, #35, #2, #6, #46 and #57) and in resident common areas. The facility census was 59. Review showed the facility did not provide a pest control policy. 1 Review of Resident #54's face sheet (admission data) showed the resident admitted to the facility on [DATE]. Review of the resident's quarterly minimum data sheet (MDS - a federally-mandated assessment form completed by facility staff), dated 01/05/24, showed the following: -Moderately impaired cognitive ability; -Required supervision of staff while eating; -Dependent on staff for toileting hygiene and showers; -Substantial/maximum assistance of staff with personal hygiene and dressing. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement policies to prevent possible abuse, neglect, or misappropriation of residents when the facility failed to complete a Family Care Safety Registry (FSCR - a state registry that provides multiple checks on staff including a Criminal Background Check) or a Criminal Background Check (CBC) prior to hire to ensure two staff (Certified Nursing Assistant (CNA) J and Certified Medication Technician (CMT) K), did not have a disqualifying criminal background that would prevent the staff member from working in a certified long-term care facility; failed to perform an Employee Disqualification List (EDL) check on three staff (CNA J, CNA M, and CMT K); [...]

Inspectors wroteBased on record review and interview, the facility failed implement a comprehensive person-centered care for each resident when staff failed to complete a comprehensive and individualized care plan, including interventions, to address the specific needs of four residents (Resident #24, #30, #31, and #38) out of a sample of 22 residents. The facility had a census of 59. Review of the facility's policy, titled Care Plans, dated 01/01/24, showed the following: -It is the policy of the facility to promote continuity of care and communication among staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission. Each resident will have a person-centered comprehensive care plan developed and implemented to meet his/her preferences and goals and address the resident's medical, physical, mental, and psychosocial needs; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to notify the physician of a change in condition for one resident (Resident #30) when the resident complained to a nurse of pain, and stinging and burning in his/her legs, and expressed concerns about the possibility of urinary sepsis (a potentially life-threatening condition that arises when the body's response to infection causes injury to it's own tissues and organs). A sample of 22 residents were reviewed in a facility with a census of 59. Review of the facility policy titled, Resident Change in Condition, dated 01/01/24, showed the following: -The facility will keep the physician, who is in charge of the resident's medical care, informed of the resident's medical condition so they may direct the plan of care as needed; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a bed-hold policy to one resident (Residents #39), out of a sample of four residents, who transferred to the hospital. The facility census was 59. Review of the facility's policy titled Bed Hold Policy, undated, showed before and at the time the facility transfers a resident for hospitalization or therapeutic leave, the facility will provide resident or resident's representative with written notice explaining the duration of the bed-hold policy. 1. Review of Resident #39's face sheet (a document that gives a patient's information at a quick glance) showed the following: -admission date of 01/28/21; -The resident was his/her own responsible party; -Diagnoses included diabetes (a metabolic disease, involving inappropriately elevated blood glucose levels), reduced mobility, and fracture of right lower leg. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Minimum Data Sets (MDS - a federally mandated assessment instrument completed by facility staff) were accurate for all residents when staff failed address one resident's (Resident #55) anti-anxiety medication on the resident's MDS. The facility census was 59. Review of the facility's policy titled Resident Assessment Instrument, dated 01/01/24, showed the following: -It is the policy of the facility to adhere to the following procedures related to the proper documentation and utilization of a resident's MDS to ensure a comprehensive and accurate assessment of residents will be completed in the format and in accordance with time frames stipulated by the Department of Health and Human Services Center for Medicare and Medicaid Services (CMS). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all dependent residents received services necessary to maintain good grooming and personal hygiene when the staff failed to provide assistance with bathing to two dependent residents (Resident #55 and Resident #31) and failed to provide assistance with shaving to one resident (Resident #55) in out of a sample of two residents. The facility's census was 59. Review of the facility's policy titled Know Your Rights, undated, showed the following: -Residents of nursing homes have rights that are guaranteed by the federal Nursing Home Reform Law. The law requires nursing homes to promote and protect the rights of each resident and stresses individual dignity and self-determination. Many states also include residents' rights in state law or regulation; -Right to self-determination: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the physician signed the Outside the Hospital Do Not Resuscitate (DNR - do not attempt cardiopulmonary resuscitation (CPR-an emergency procedure that is performed when a person's heartbeat or breathing has stopped)) order for two residents (Resident #35 and Resident #57) out of a sample of four residents. The facility census was 59. Review of the facility's policy titled Code Status, (the level of medical interventions a resident wishes to have if their heart or breathing stops), dated [DATE], showed the following: -It is the policy of the facility to honor code status of the resident in accordance to State and Federal Regulations; -During the admission process the Social Services Designee (SSD) or charge nurse will discuss with each resident and/or the person accompanying the resident the following: [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to consistently track and monitor the dry, scaly skin with multiple nodules to bilateral lower extremities skin condition for one resident (Resident #24) and failed to follow, physician ordered blood pressure parameters for determining administration of an antihypertensives (blood pressure) medication for one resident (Resident #54) out of 22 sampled residents in a facility with a census of 59. 1. Review of facility policy titled Skin Assessments, dated 01/01/24, showed the following: -Facility should accurately record any chronic or acute abnormalities of resident's skin; -Skin assessment should be performed and documented weekly; -Nursing assessment should include lesions, redness or rash, edema (swelling), skin tears, abrasions, bruises, pressure injuries, cyanosis (blue color), and surgical wounds. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed ensure residents did not experience a reduction in range of motion unless unavoidable when staff failed to evaluate the need for restorative therapy for one resident (Resident #11) who expressed concerns with his/her decreased hand/finger range of motion (ROM) and expressed a desire for restorative therapy. A sample of 22 residents was reviewed in a facility with a census of 59. 1. Review of Resident #11's face sheet showed an admission date of 01/18/19 and readmission date of 01/07/24. Review of the resident's February 2024 physician orders showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents only had catheters (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) when necessary when staff obtained an order for a catheter for one resident (Resident #24) without a documented clinical condition that demonstrated necessity. The facility census was 59. Review of the facility policy titled, Indwelling Urinary Catheters, dated 01/01/24, showed it was the policy of the facility that indwelling urinary catheters should be used only when a medical condition exists requiring the use of the catheter. 1. Review of Resident #24's face sheet (document that gives a resident's information at a quick glance) showed the following: -admission date of 05/11/23; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents maintained acceptable parameters of nutrition, unless unavoidable, when staff failed complete physician ordered weekly weights and failed to care plan weekly weights and new interventions for weight loss for one resident (Resident #36) with weight loss out of two sampled residents. The facility's census was 59. Review of the facility's policy titled Resident Weights and Weight Management, dated 01/01/24, showed the following: -It is the policy of the facility to accurately measure and record residents' weights to provide a baseline and track weights as an indicator of nutritional status and medical condition of the resident. Residents should be weighed on admission and monthly, unless otherwise indicated; [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide respiratory care per standards of practice when staff failed to administer oxygen as ordered for two residents (Residents #31 and #49). The facility census was 59. Review of facility policy titled Supplemental Oxygen, dated 01/01/24, showed the facility shall provide oxygen to any resident with a doctor's order for treatment of certain diseases or conditions. 1. Review of Resident #31's face sheet (a general information sheet) showed the following: -admission date of 04/11/23; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dialysis (the cleaning of the blood with a machine due to the kidneys not working) services per professional standards of practice when the facility failed to have a contract with the dialysis provider, failed to document routine assessment and monitoring of the dialysis site, and failed to document ongoing communication with the dialysis center for one resident (Resident #31) who received dialysis. The facility census was 59. Review of the facility's policy Dialysis Service, dated 02/18/24, showed the following information: -The facility must ensure that residents that require dialysis service receive services consistent with the professional standards of practice, comprehensive person-centered care plan, and residents' goals and preferences; -Facility shall ensure transportation to and from dialysis 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide trauma-informed care in accordance with standards of practice when staff failed to identify, assess, care plan, and provide supportive interventions for one resident (Resident #41) with a diagnosis of Post-Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) out of one sampled resident. The facility's census was 59. Review showed the facility did not provide a policy related to Trauma Informed Care. 1. Review of Resident #41's face sheet (a document that gives a patient's information at a quick glance) showed the following: -admission date of 09/12/23; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician responded timely to a pharmacist's request to discontinue a medication during the monthly drug regimen review for one resident (Resident #54) out of 22 sampled residents in a facility with a census of 59. 1. Review of Resident #54's face sheet showed an admission date of 03/29/23. Review of the resident's quarterly Minimum Data Set (MDS - a federally-mandated assessment tool completed by facility staff), dated 01/05/24, showed the following: -Moderate cognitive impairment; -No symptoms of depression and no problem behaviors; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #30) did not receive unnecessary drugs when staff administered two different antibiotics simultaneously, despite physician directions to the contrary, out of 22 sampled residents in a facility with a census of 59. 1. Review of Resident #30's face sheet showed: -admission date of 09/26/22 and re-admitted on [DATE]; -Diagnoses of type 2 diabetes mellitus, hypertension (high blood pressure), dysuria (painful or uncomfortable urination), muscle weakness, history of sepsis (a potentially life-threatening condition that arises when the body's response to infection causes injury to it's own tissues and organs), and history of urinary tract infections. Review of the resident's current physician orders showed: [...]

Inspectors wroteBased on record review, observation and interview the facility failed to ensure a medication regimen was free from unnecessary psychotropic medications when the facility failed to document target behaviors for administration of antipsychotic medications and reevaluate a gradual dose reduction (GDR-a step wise tapering of a dose to determine if symptoms, conditions, or risk can be managed by a lower dose or if the dose or medication can be discontinued) for one resident (Resident #16) and failed to document use of other non-pharmacological interventions, target behaviors, and adverse reactions for one resident (Resident #57) out of a sample of 22 residents. The facility's census was 59. Review of the facility's policy titled Behavioral Health Services, dated 01/01/24, showed the following: [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure a medication error rate of less than 5% when staff made two errors out of 25 opportunities resulting in an 8% error rate. Staff administered medication when the blood pressure was out of the parameter for medication to be given for one resident (Resident #31) and failed to assess resident's pulse rate prior to administration for one resident (Resident #46) during random medication pass observations. The facility had a census of 59. Review of the facility's Medication Administration Policy, dated 01/01/24, included the following information: -It is the policy of the facility to safely and accurately administer physician ordered medication to each resident. -Record vital signs as ordered before administering medications; -Follow physician orders regarding holding medications based on a vital sign parameter; [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure resident funds were placed in an account separate from the facility operating account. The facility did not provide residents with refunds of their personal funds from the operating account in a timely manner for four residents (Resident #10, #20, #21 and #22). The facility census was 65. 1. Record review of the facility maintained Accounts Receivable Report for the period 12/01/22 through 12/13/23, showed the following residents with personal funds held in the facility operating account; Resident Amount Held in Operating Account #10 $700.04 #20 $344.26 #21 $928.00 #22 $1,228.05 Total $3,200.35 During an interview on 12/13/23 at 5:00 P.M., the Business Office Manager said credits should have been refunded timely and did not know why the money had not been refunded.

Inspectors wroteBased on record review and interview, the facility failed to designate a registered nurse (RN) to serve as the Director of Nursing (DON) on a full time basis. The facility census was 61. Record review of a facility document entitled Director of Nursing (undated) , showed the following information: -Objective to maintain effective and efficient operations of the facility, to ensure resident provision of appropriate care, safety and optimal level of functioning; -Daily Tasks included be available at least, within the facility between the hours of 8:00 A.M. and 5:00 P.M., except for prearranged situations; on call for medical issues; review of physician orders against telephone and written orders; hall rounds to monitor resident care (at least twice daily); and monitoring of change of condition charting; [...]

Inspectors wroteThis deficiency is uncorrected. For previous examples, please refer to the Statement of Deficiencies dated . Based on observation, interview, and record review, the facility failed to provide an effective, thorough program for the prevention of the growth of the Legionella bacteria (a bacteria which causes a respiratory disease when breathing in small droplets of water in the air that contain Legionella. It can become a health concern when it grows and spreads in human-made water systems.) in the facility water supply or where moist conditions existed. Additionally, the facility failed to maintain an effective infection control program when staff failed to wear N95 masks appropriately. The facility census was 61. 1. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure a clean homelike environment when staff failed to clean one cloth recliner and one cloth couch in the special care unit (SCU). The facility census was 61. 1. Observations of the SCU television room showed the following: -On 12/7/21, at 10:47 A.M., Resident #38 sat on a cloth recliner in the SCU television room. Several dried white spots, some crusted with white debris, stained the arms of the cloth recliner. -On 12/8/21, at 11:37 A.M., and 12/9/21, at 12:17 P.M., the cloth recliner had several dried white spots, some with crusty debris, on the arms and seat of the cloth recliner. The cloth couch had a dark liquid-type substance pooled on the seat of the couch that dripped down the front of the couch. [...]

Inspectors wroteBased on interview and record review, the facility failed to fully implement the facility's abuse prevention policies when staff did not check the Nurse Aide (NA) Registry prior to hiring four out of ten sampled staff (Registered Nurse (RN) N, [NAME] M, Business Office Manager (BOM) L, and Laundry Services O) to ensure they did not have a Federal Indicator (a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) prohibiting them to work in a certified facility. The facility's census was 61. Record review of the facility's policy entitled Abuse Prevention, dated 2/18/2015, showed the following: -All applicable licenses or registries shall be called and verification of license obtained; -Written verification of the call shall be placed in the employee's permanent record; [...]

Inspectors wroteBased on observation, interview and record review the facility failed to have a system in place to provide consistent showers for two residents (Residents #48, and #56) who resided on the special care unit and one resident (Resident #4) who resided in the main facility. The facility census was 61. Record review showed the facility did not provide a bathing/showering policy. 1. Record review of Resident #48's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admitted to the facility on [DATE] and readmitted on [DATE]; -The resident had a responsible party; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to routinely provide individualized and meaningful activities to the residents of the Special Care Unit (including Resident #38, Resident #45, Resident #48 and Resident #56) Fifteen residents resided on the SCU and the facility census was 61. Record review of the facility's undated policy titled Activities Meet Interest/Needs of Each Resident, undated, showed the following: -It is the policy of the 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 quality of life, and honor and support these principles for each resident; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a a risk/benefit review and document alternatives attempted prior to bed rail use, failed to obtain informed consent for the use of bed rails, and failed to complete a bed rail safety check to include measurements of the bed frame and bed rails for risk of entrapment for three residents (Residents #4, #10, and #34). The facility failed to care plan the use of the bed rail for one resident (Resident #4). The facility census was 61. Record review of a facility document entitled Procedure: Bedrails, date blank, showed the following information: -The facility shall provide adequate management of bedrails to ensure that residents attain or maintain the highest practicable physical, mental, and psychosocial well-being; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide all residents reasonable access to the use of a phone when the facility did not have a phone the one resident (Resident #56) could use to talk with family while on isolation precautions due to coronavirus disease 2019 (COVID-19- an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)). The facility census was 61. Record review showed the facility did not provide a policy related to providing forms of communication with privacy to every resident. 1. Record review of Resident #56's face sheet (a document that gives a patient's information at a quick glance) showed the following: -admission date of 07/28/21; -Resident had a guardian; -No medical diagnoses listed. Record review of the resident's care plan, dated 9/15/21, showed the following: [...]

Inspectors wroteBased on record review and interview, the facility failed to notify the resident and/or the resident's representative in writing of a transfer to a hospital, including the reasons for the transfer, and failed to provide the Ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) a copy of the notification or monthly log showing transfers, for two residents (Residents #4 and #13). The facility census was 61. Record review showed the facility did not provide a policy regarding notifications upon transfer to a hospital. 1. Record review of the facility monthly Transfer/Discharge Log, dated March 2021, showed the following: -Resident #4 was transferred to the hospital on 3/12/2021 for an unplanned evaluation, admitted to the hospital, and returned to the facility on 4/1/2021; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to identify, document on, and treat new non pressure wounds on the feet of one resident (Resident #45) in a timely manner. The facility's census was 61. Record review of the facility's Wound Prevention Program policy, undated, showed the following: -The purpose of this program is to assist the facility in the care, services and documentation related to the occurrence, treatment, and prevention of pressure as well as, non-pressure related wounds; -Weekly skin checks will be conducted by the licensed nurse. This will be documented in the resident's Electronic Medical Record (EMR); -Daily, during routine care, the Certified Nursing Assistant (CNA) will observe the resident's skin. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep one resident (Resident #56) free from possible harm by not supervising the resident while smoking as care planned and by not providing a receptacle to put used cigarette butts. The facility also failed to keep residents who reside in the special care unit (SCU) free from possible harm by not securing hazardous chemicals, cigarettes, and a lighter in a small storage room in the dining room. Fifteen residents resided on the SCU and the facility census was 61. 1. Record review of the facility's undated policy titled Smoking Policy showed the following: -It is the policy of Roaring River Rehab and Health to allow residents to smoke in designated areas; -Smokers will dispose cigarette butts in the appropriate available receptacles; [...]