Aspire Transitional Care

Inspectors wroteThe facility failed to ensure that an allegation of resident abuse was reported to all applicable agencies for 3 out of 4 residents. Based on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to ensure an allegation of resident abuse was reported to all applicable state agencies for 3 out of 4 residents (#57, #58, and #59). The deficient practice could result in further allegations of abuse not being reported and investigated by the appropriate state agencies.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to ensure proper infection control practices were implemented during wound care for one of one sampled residents (Resident #62). The deficient practice could result in the transmission of infection. Findings Include:Resident #62 was admitted to the facility on [DATE], with diagnoses that included infection and inflammatory reaction due to internal fixation device of the right tibia, bacteremia, end-stage renal disease, and Type 2 diabetes mellitus. During the initial pool screening on August 19, 2025, Resident #62 revealed he had a wound to his right lower extremity. He stated that nurses change the dressing every day. [...]

Inspectors wroteBased on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to ensure an allegation of resident abuse was reported to all applicable state agencies for 3 out of 3 residents (#3, #7, and #5). The deficient practice could result in further allegations of abuse not being reported and investigated by the appropriate state agencies.

Inspectors wroteBased on personnel file review, staff interviews, facility policy review, the facility failed to ensure that two of ten sampled staff (Staff # 19 and #49) had current Cardio Pulmonary Resuscitation (CPR) certification. The deficient practice could result in staff not knowledgeable of how to provide emergency care to residents.

Inspectors wroteBased on record review, observations, staff and resident interviews, and policy review, the facility failed to ensure that the environment remained free from accident hazards for 3 residents (#281, #26, and #482). The deficient practice could result in potential harm to residents due to unsupervised access to sharps.

Inspectors wroteBased on observations, staff interviews, and review of clinical records and policy the facility failed to ensure dialysis care and services, including nutrition, assessments, or coordination of care, were appropriately followed for 3 Residents (#15, #10, and #234). The deficient practice may result in complications of care and services to residents receiving dialysis.

Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to ensure that medications and controlled substances were kept locked. The deficient practice could result in residents, staff, and visitors having access to medications.

Inspectors wroteBased on observations, staff interviews, resident interviews, and policy review, the facility failed to ensure that food was stored under sanitary conditions that maintained freshness in the kitchen fridge and nourishment refrigerator. The deficient practice could result in potential foodborne illness.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation, and facility policy, the facility failed to ensure that clinical records accurately reflected care and services provided to two out of two sampled residents (#281 and #19), regarding fluid restriction, care interventions, and the use of an air mattress. The deficient practice has the potential for clinical records to inaccurately and incompletely reflect the status of residents and alter the actual care that is provided. Findings Include: - Regarding Resident #281 regarding fluid restriction: Resident #281 was admitted to the facility on [DATE] with diagnoses that included unspecified injury of head, dementia, unsteadiness on feet, repeated falls, syndrome of inappropriate secretion of antidiuretic hormone, and hypo-osmolality and hyponatremia. [...]

Inspectors wroteBased on closed record review, staff interviews, and policy review the facility failed to ensure that proper documentation was provided to responsible parties and the receiving facility(short-term general hospital) for 1 of 2 sampled residents (#29) and one of two sampled residents ( #29) received proper notice of discharge. The deficient practice could lead to notifications of resident transfer/discharge not being made to all required parties.

Inspectors wroteBased on observation, record review, interviews, and facility policy review, the facility failed to ensure one of one sampled resident (#19) had a baseline care plan and/or comprehensive care plan to address the resident's immediate needs within 48 hours of admission regarding his weightbearing status and proper use of orthotic. The deficient practice could result in a resident not receiving the necessary care, services, or assistance, leading to harm.

Inspectors wroteFinding Include: Resident #432 was admitted on [DATE] with Alzheimer's Disease, Dementia, Unspecified Severity with Anxiety, Acute Respiratory Failure with Hypoxia, Hypertensive Chronic Kidney Disease with stage 1 through 4 Chronic Kidney Disease, Unspecified Protein-Calorie Malnutrition, and Chronic Kidney Disease, Stage 3 Unspecified. Review of Nurse's note on 08/08/2024 revealed that the nurse was notified that resident #432 had tripped and fallen in her room, due to her long oxygen tubing that became trapped around the resident's wheelchair. The nurse's note also revealed that she was notified by the Certified Nursing Assistant (CNA) that housekeeping helped the patient off the floor into her wheelchair on 08/08/24 at 2:35PM. [...]

Inspectors wroteBased on the clinical review, interviews, facility documentation and policy review, the facility failed to maintain Enchanced -Based Precautions (EBP) for 2 of 5 sampled residents (#430, #234). The deficient practice could result in spread of infection. Findings Include: - Regarding Resident #430: Resident #430 was admitted on [DATE] with diagnosis Type 2 diabetes mellitus, atherosclerotic heart, necrotizing fasciitis, chronic respiratory failure with hypoxia, acute on chronic systolic (congestive) heart failure, hypokalemia, hypomagnesemia and klebsiella pneumoniae. Physician orders included to wear PPE (Personal Protective Equipment) for Enhanced Barrier Precaution (EBP) and to use EBP sign as refers for direct care. The order also included that staff would need to wear non-sterile gown, gloves, every shift for wound care. [...]