Aspire Physical Recovery Center At Hoover, LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and facility document and policy review, it was determined the facility failed to provide care and treatment in accordance with professional standards of practice to meet the needs of five (Residents #98, #141, #454, #112, and #300) of 50 sampled residents. Specifically, the facility failed to: 1. Obtain orders for the care and monitoring of a peripherally inserted central catheter (PICC) line for Resident #98; 2. Transcribe orders for care of a surgical wound for Resident #141; 3. Ensure care of a surgical wound was completed as ordered for Resident #112; and 4. Ensure coordination between the facility and Resident #300's hospice provider regarding who would provide the resident's medications while in the facility for respite care (generally a short-term temporary admission, usually for residents receiving hospice benefits). As a result, Resident #300 did not receive their medications as ordered by a physician. Findings included: 1. A review of a FACE SHEET indicated the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to assess residents for the ability to self-administer medications for one (Resident #60) of four residents reviewed during medication pass observation. Findings included: Review of a facility policy titled, Medication Administration Procedures Self-Administration of Medications, dated 04/2020, revealed, .Residents who desire to self-administer medications are permitted to do so if the facilities interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility. An order to self-administer must be given by the physician. 1. Upon request of a resident to self-administer medications, the interdisciplinary team and physician will be consulted for evaluation. 2. Facility staff will administer the resident's medications until the interdisciplinary team completes an assessment and a physician order is obtained. 3. The interdisciplinary team…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, record review, and review of facility policy titled Resident Assessment Instrument (RAI) , the facility failed to ensure one (Resident #1) of one resident was assessed for appropriate adaptive equipment related to call lights. Findings included: A review of the facility's policy titled, Resident Assessment Instrument (RAI), dated 10/29/2015, revealed, .Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop a plan of care . A review of FACE SHEET indicated the facility admitted Resident #1 on 10/17/2022 with diagnoses that included Multiple Sclerosis and Muscle Spasms. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/23/2023, revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. The MDS indicated Resident #1 required extensive assistance from staff with transfers, locomotion on and off the unit, dressing, eating, toileting, personal hygiene, and bathing. The resident had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and facility policy titled Discharge Summary and Plan of Care, it was determined that the facility failed to have a completed discharge summary with a recapitulation (concise summary) of the residents' stay for two (Resident #98 and Resident #453) of two residents reviewed for discharge requirements. Findings included: Review of a facility policy titled, Discharge Summary and Plan of Care, dated 11/28/2016, revealed, .The Discharge Summary should include: - A recapitulation of the resident/guest's stay - A final summary of the resident/guest's status at the time of discharge - A post discharge plan of care developed with the resident/guest and his/her family, which will assist the resident/guest to adjust to his/her new living environment - A reconciliation of pre and post discharge medications should be conducted . 1. Review of a FACE SHEET indicated the facility admitted Resident #453 on 12/27/2022. Review of the discharge Minimum Data Set (MDS), with an Assessment Reference…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews, record review, and facility policy review, it was determined that the facility failed to ensure medications were available from the pharmacy for two (Resident #452 and Resident #142) of six residents reviewed for unnecessary medications. Specifically, the facility failed to ensure Resident #452's Prednisone and Resident #142's inhaler was available from the pharmacy for administration. Findings included: Review of a facility policy titled, Medication Policies Ordering and Receiving Medications from Provider Pharmacy, dated 04/2020, specified, .Medications and related products are received from the provider pharmacy on a timely basis. Procedures 1. A. New medication orders are transmitted to the pharmacy. C. The first dose of non-emergency medication is scheduled to be given after the regularly scheduled pharmacy delivery to the facility . 1. A review of a FACE SHEET indicated the facility admitted Resident #452 on 05/26/2023 with diagnoses that included Asthma and Acute Respiratory Failure with Hypoxia (below normal level of oxygen in the blood). The resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, facility document review, and facility policies titled Medication Administration-General Guidelines and Blood Glucose Testing the facility failed to ensure adequate monitoring of blood glucose (sugar) levels as ordered by the physician for the use of insulin for Resident #143 and #294, two of five residents reviewed for unnecessary medications. Findings included: Review of a facility policy titled, Medication Administration-General Guidelines, dated 2011, specified, . Medications are administered in accordance with written order of the attending physician . A review of a facility policy titled, Blood Glucose Testing, revised on 10/01/2019, revealed, .The physician's order should specify the type of specimen to be obtained. Blood glucose levels for residents with diabetes vary, depending on food intake, medication, and exercise . A review of Resident #143's FACE SHEET revealed the facility admitted the resident on 03/16/2023 with diagnoses that included Type Two…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, the facility policy titled, Incidents and Accidents, and interviews, the facility failed to maintain medical records for residents that were complete and accurately documented for two (Resident #141 and Resident #106) of 27 sampled residents. Specifically, 1) the facility failed to document the administration of medications for Resident #141. 2) the facility failed to complete an incident report when Resident #106 was found on the floor on 04/18/2023. Findings included: 1) A review of Resident #141's FACE SHEET revealed the facility admitted the resident on 03/15/2023 with diagnoses that included Aftercare Following Joint Replacement Surgery, Anxiety Disorder, Hypertension, Gastro-esophageal Reflux Disease (GERD), and Hypokalemia (low potassium). A review of the five-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/22/2023, revealed Resident #141 was independent with daily decision making according to the Staff Assessment for Mental Status. The resident was independent with eating and personal hygiene; required supervision from staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews and review of facility policies, titled Leftover Food Storage and Use, Food Storage Temperature Logs, FOOD STORAGE TEMPERATURE LOG,' and Food from Families and Friends, the facility failed to ensure: 1. food in the kitchen freezer was labeled with an open and use by date, 2. PM temperatures were logged on 3/17/21 for the resident's supplement refrigerator on the 400 hall, and, 3. food item in the resident's supplement freezer was labeled. This had the potential to affect 73 of 73 residents who received meals from the kitchen and 30 residents who had the potential to utilize the supplement refrigerator on the 400 hall. Findings Include: 1. A review of a facility policy titled, Leftover Food Storage and Use with an Effective date of Sept. 12, 2019 revealed . Purpose: To Assure that food borne illnesses are avoided.PROCESS: . b. Leftover foods should be covered, labeled and dated. On 3/16/21 at 12:47 PM a tour of the facility kitchen was conducted with Employee Identifier (EI) #2, Dietary Manager (DM). The walk in freezer was observed to have three…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and review of a policy titled Perineal Care, the facility failed to ensure a Certified Nursing Assistant (CNA), changed her gloves during incontinent care before placing the clean brief for Resident Identifier (RI) #9. This affected one of two residents observed for incontinent care. Findings Include: A review of a facility policy Perineal Care with an effective date of 10/1/2010, revealed: PURPOSE: Good perineal care helps prevent infection, irritation and skin breakdowns. RI #9 was admitted to the facility on [DATE] with a diagnosis of Personal History of Urinary Tract Infections. On 3/18/21 at 3:08 PM, Employee Identifier (EI) #4, CNA, entered RI #9's room for the provision of incontinent care. EI #4 lowered the head of the bed, explained the procedure, washed her hands and donned gloves. EI #4 removed the soiled brief and provided the perineal care. EI #4 placed and secured the clean brief with the same gloves she used to clean RI #9. On 3/18/21 at 3:41 PM, an interview was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of the facility policy titled Food Receipt and Storage and the 2017 FDA Food Code, the facility failed to ensure: 1. staff placed a large pan of frozen crab cake meat on the shelf, off of the floor in the walk in freezer; 2. food items in the walk-in freezer and reach-in freezer were sealed; and 3. a dented can of baked beans was removed from active service storage. This had the potential to affect 106 out of 106 residents receiving meals from the kitchen. Findings include: A review of the facility policy titled, Food Receipt and Storage, with an effective date of August 23, 2017 revealed: .Purpose: Foods should be received and stored properly . Standard: Foods should be . stored in accordance with FDA Food Code recommendations. Process: . II. Storage of Foods: . c. Items . should be kept at least 6 inches from the floor. f. Place dented, . cans, . in a separate area . k. Open food items should be covered, . A review of the 2017 FDA Food Code page 80 revealed, . 3-305.11 Food Storage (A) Except as specified in (B) and (C) of this section,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, interview, and review of a facility policy titled, Disposal of Medications Non-Controlled Medication Destruction, the facility failed to ensure the required signatures were on nine of nine Non-Controlled Record of Medication Destruction Sheets for the month of February, 2020. This affected one of five months of Non-Controlled Medication Destruction Records reviewed. Findings Include: Review of a facility policy titled, Disposal of Medications Non-Controlled Medication Destruction, dated 3/2011, revealed: . 3. The registered nurse and/or pharmacist witnessing the destruction ., ensures that the following information is entered on the Record of Medication Destruction form . J. Signature of witnesses, two witnesses required for non-controlled substances . in the designated areas on the destruction form. On 02/13/20 at 9:41 a.m., the surveyor reviewed the facility's Non-Controlled Drug Destruction Book. A review of the February 2020, Non-Controlled Medication Destruction Sheets, revealed nine of nine sheets dated 02/06/2020, did not contain required two…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.