Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aspire Senior Living New Florence during CMS and state inspections, most recent first.
Failure to implement an Antibiotic Stewardship Program was identified after interview and record review showed the facility did not have a process to track and trend antibiotic use. The facility policy called for protocols to optimize infection treatment and a facility-wide system to monitor antibiotic use, but the ADON/infection preventionist left and the administrator said it was still unknown what had or had not been done because no information was left at the facility.
The facility failed to designate a qualified IP for its infection prevention and control program. The IP policy directed staff to assign a qualified individual to implement infection prevention and control activities, but the ADON who had been serving as the IP left the facility, and the administrator stated the facility did not currently have an IP. The census was 50.
Failure to Maintain Facility Areas in Good Repair: Staff did not keep the building exterior, spa areas, and a resident room in good repair. Surveyors observed missing shingles and rotted decking on the roof with holes exposing the attic, cracks and gaps in the spa walls, and a large hole in a resident room wall exposing the wall cavity. The maintenance director acknowledged awareness of the issues and said the resident room hole had been present for quite a while.
Missing Bed Rail Entrapment Assessments: Staff failed to document entrapment assessments for two residents with bed rails in place. One resident was cognitively intact with a seizure disorder and had bilateral U bars upright in bed; another was cognitively intact with MS and upper/lower extremity impairments and had a quarter-length bed rail upright. The Maintenance Director said the assessments were completed but not documented, and the Administrator said bed rail checks were expected.
Failure to maintain an effective QAPI program. Facility records showed no documentation of a QAPI/QA program, and the administrator stated there was no information available to provide and that the program would have to be started from scratch. The facility's plan described a quarterly, facility-wide performance improvement process, but records also showed QAPI had not previously been done.
Infection prevention and control failures were identified in water management, TB screening, and wound care. The facility’s water program lacked facility-specific control measures and control limits, and brown water was observed in a resident sink. Employee TB screening records were incomplete for several staff, including missing or late two-step PPD documentation, and resident TB screening was missing for multiple residents. During wound care, an RN used poor hand hygiene and glove practices, placed soiled items on clean barriers, wore PPE out of the room, and handled multiple wounds in a way that did not keep clean and dirty tasks separated.
Facility staff failed to provide written bed hold information to three residents or their representatives when the residents were transferred to the hospital. The facility policy required notification upon admission, transfer, or therapeutic leave, but the records for all three residents lacked documentation that a bed hold notice was issued. The DON was uncertain about the policy, and the administrator said the discharging nurse was responsible for giving the notice and obtaining a signature, but was not sure the process was being followed.
Facility staff failed to develop complete person-centered care plans for three residents. Two residents had hospice services/orders, and one resident had an indwelling catheter, but these needs were not documented in the care plans. The DON stated hospice care and catheter care should be care planned, while the administrator said the care plan process was handled by a coordinator from another home and was unaware the items were missing.
Failure to Update Care Plans for Changed Resident Conditions: The facility did not review and revise care plans when residents’ needs changed for multiple residents. Several residents had documented unwitnessed falls, but their care plans were not updated with new fall interventions. One resident’s code status remained listed as full code despite DNR orders, and another resident’s care plan was not updated after a Foley catheter was removed. The DON and administrator acknowledged care plans should reflect changes in condition and interventions.
Nurse aide annual in-service training was not provided as required. CNA G, NA H, and CNA I had no documentation of the minimum 12 hours of yearly education, including dementia care and abuse prevention training, even though the facility had residents with dementia and/or Alzheimer’s disease. The DON said the required trainings had not been set up or implemented, and the administrator said he/she was unaware the aides were not receiving the education.
Facility staff did not ensure an RN was present for at least eight consecutive hours per day as required, with staffing records showing multiple days where no RN was assigned. Interviews with the Staffing Coordinator, interim DON, and administrator confirmed awareness of the requirement but cited limited RN availability and scheduling issues as reasons for the deficiency.
Facility staff did not post or maintain required daily nurse staffing information, including staff hours and census, as mandated by policy. Observations and record reviews confirmed the absence of posted data and missing records for several months. Interviews revealed that key staff were unaware of their responsibilities regarding staffing information.
Facility staff failed to document wound treatments for a resident, leading to an infection, and did not perform neurological assessments after the resident experienced a fall. These deficiencies were identified during a review of records and interviews, affecting one resident out of three sampled in a facility with a census of 51.
The facility failed to properly screen four staff members for TB and did not adhere to hand hygiene protocols in the dietary department. Observations showed lapses in handwashing techniques and glove changes, contrary to facility policy. The administrator was unaware of the incomplete TB tests and attributed the oversight to staffing changes.
The facility failed to maintain accurate accounting for resident funds and did not provide quarterly bank statements from March to July 2024. The issue arose due to a transition in staff, affecting 25 residents. The Corporate AR and BOM were responsible for these tasks, but the accounts were not reconciled monthly, and statements were sent late.
Facility staff failed to refund personal funds to six discharged residents, with balances held in the facility's operating account. The facility lacked a Business Office Manager since February, and the corporate team was responsible for managing accounts. The administrator was unaware of the outstanding balances, and the Corporate Accounts Receivable acknowledged the oversight, stating that monthly reviews were not conducted due to a transition in responsibilities.
The facility failed to complete required pre-employment screenings for six employees, including CBC, EDL, FCSR, and CNA registry checks. This oversight occurred due to a lack of specific policy instructions and a change in personnel responsible for these tasks, with the new HR person unaware of the incomplete screenings.
Facility staff failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in care. A resident receiving hospice services did not have hospice care included in their plan. Another resident's care plan contained conflicting code status information. A resident with pressure ulcers lacked instructions for moon boots, and a resident with cognitive impairment and wandering behavior had multiple unmet care needs, including hospice services and weight monitoring.
Failure to Implement Antibiotic Stewardship Monitoring
Penalty
Summary
Failure to implement an Antibiotic Stewardship Program was identified based on interview and record review. The facility’s policy, titled Antibiotic Stewardship, stated that the purpose of the program was to develop and implement protocols to optimize treatment of infections, ensure residents who require an antibiotic are prescribed the appropriate antibiotic, reduce the risk of adverse events from unnecessary or inappropriate antibiotic use, and develop, promote, and implement a facility-wide system to monitor antibiotic use. Review of the facility’s antibiotic stewardship program showed staff did not have a process in place to track and trend antibiotic usage. During an interview, the administrator stated the ADON had been the infection preventionist and was supposed to work on starting the Antibiotic Stewardship process, but the ADON left the facility and it was still unknown what had or had not been done because no information was left at the facility.
No Designated Infection Preventionist
Penalty
Summary
The facility failed to designate one or more individuals with specialized training in Infection Prevention and Control as the Infection Preventionist for its infection prevention and control program. The facility's Infection Preventionist policy, dated undated, directed staff to designate a qualified individual or individuals responsible for implementing programs and activities to prevent and control infections. During an interview on 09/25/25 at 8:05 A.M., the administrator stated that the Assistant Director of Nursing had been serving as the infection preventionist but left the facility on 09/09/25, and the administrator said the facility did not currently have an Infection Preventionist. The census was 50.
Failure to Maintain Facility Areas in Good Repair
Penalty
Summary
The facility failed to provide a clean, homelike, and comfortable environment when staff did not maintain resident rooms, common areas, medical device equipment, and the exterior of the building in good repair. During the Life Safety Code tour, surveyors observed the mansard roof on the north side of the facility with multiple missing shingles exposing the wood decking, rotted decking material, and two holes exposing the attic space. Surveyors also observed two wall corners in the 100 hall spa behind the toilet with cracks extending from the floor to the ceiling, a gap between the tile floor and the baseboard behind the toilet, and a large rectangular hole in a resident room wall below the resident's desk exposing the wall cavity. The maintenance director stated he/she was responsible for ensuring interior and exterior repairs were completed and acknowledged awareness of the roof holes, spa wall cracks, and the hole in the resident room. The maintenance director said the facility had been under new ownership since May and that he/she was working with corporate staff to get the roof repaired and the two spas remodeled, but did not know the status of the repair or remodel plans. The maintenance director also stated the hole in the resident room had been there for quite a while but had not yet been repaired. The administrator stated the maintenance director was responsible for keeping the facility in good repair and was aware of the roofing and spa issues, but was not aware of the hole in the resident room.
Missing Bed Rail Entrapment Assessments
Penalty
Summary
Facility staff failed to complete entrapment assessments for two residents with bed rails in place. The facility policy titled, Bed/Assist Bars Use in Long-Term Care, dated 09/17/25, directed nursing/therapy staff to perform a risk assessment before implementation that considers entrapment risk, document the findings and rationale in the care plan, and ensure proper positioning to minimize entrapment and injury risk. Review of the medical record for Resident #2 showed the resident was cognitively intact, had a diagnosis of seizure disorder or epilepsy, and had bed rails not used as a restraint in bed; however, observation showed the resident in bed with bilateral U bars in the upright position, and the record did not contain an entrapment assessment. Review of the medical record for Resident #38 showed the resident was cognitively intact, had multiple sclerosis, impairments on both sides of the upper and lower extremities, and bed rails not used as restraints in bed; however, observation showed the resident in bed with one quarter-length bed rail in the upright position on two separate occasions, and the record did not contain an entrapment assessment. During interview, the Maintenance Director stated he/she was responsible for completing entrapment assessments on bed rails, including for new bed rails and then twice a year after initial installation, and said the assessments had been completed but not documented. The Administrator stated the Maintenance Director was responsible for completing entrapment assessments to ensure there were no loose parts or gaps and expected the bed rail to be checked monthly.
Failure to Maintain an Effective QAPI Program
Penalty
Summary
The facility failed to develop and implement an effective Quality Assurance (QA)/Quality Assurance Performance Improvement (QAPI) program that included documentation and implementation of ongoing systemic issues with resolution. Review of the facility's Quality Assurance and Performance Improvement Plan, undated, showed the purpose of the facility-wide performance improvement process was to identify and implement opportunities to improve the quality of resident care and quality of life, as well as other measures of organizational performance, with quarterly meetings involving key personnel. However, review of the Performance Improvement Program dated 09/03/25 showed the area of concern that QAPI had not been previously done. Facility records did not provide documentation of a QAPI/QA program, and during interview on 09/25/25 at 7:59 A.M., the administrator stated there was no information on a QAPI/QA program to provide and that the facility would have to start this from scratch.
Infection Prevention and Control Failures in Water Management, TB Screening, and Wound Care
Penalty
Summary
The facility failed to develop and implement complete infection prevention and control policies and procedures for its water systems. The Water Program Review dated 06/19/25 did not contain additional details, and the facility-specific program did not include control measures or control limits for identified hazardous conditions at control points such as ice machines, the main kitchen, the satellite kitchen, sinks, tubs, showers, and toilets. During the facility tour, multiple spas, an unused satellite kitchen, and multiple resident showers were observed. A bathroom sink in one resident room was observed with brown water, and a housekeeper stated water was run in resident rooms daily for about 30 seconds and that brown water had been seen in sinks that were not used regularly. The maintenance director stated housekeeping ran water in every room monthly for two minutes, but this was not documented, and the administrator stated the program should include facility-specific control measures and corrective actions for identified potentially hazardous conditions. The facility also failed to ensure employee TB screening was completed according to policy for five of ten employee files reviewed. The employee TB screening policy required a two-step Mantoux test unless there was documentation of a prior positive reaction, with the second test given within 14 days after the original test if the first was negative. Dietary D’s file lacked documentation of the second PPD, CMT E’s file lacked documentation of any PPD test, Housekeeper F’s first and second PPDs were administered after the hire date, Social Services’ file lacked a read date for the first PPD and lacked documentation of the second PPD, and CNA G’s file lacked documentation of the second PPD. The DON stated new employees should receive the two-step PPD prior to working on the floor with residents and should receive annual screening, and the administrator gave the same expectation. The facility further failed to ensure resident TB screening was completed and documented for three of six sampled residents. The resident TB screening policy directed that residents be screened upon admission and at intervals appropriate for the region, with a two-step PPD upon admission unless testing had been done by the transferring hospital within 30 days prior to admission. Resident #2, Resident #14, and Resident #18 each had admission records reviewed that did not contain documentation of a first or second step TB test. The DON stated a two-step TB should be completed on admission and annual screening should be done, and the administrator stated TB records were not being kept up to date and would be uploaded if completed. The facility also failed to provide wound care in a manner that reduced the risk of infection for two residents. Resident #6 was cognitively intact, at risk for pressure injuries, and had one unhealed stage II pressure injury; the physician order directed skin prep to the right heel twice daily. During wound care, RN A wore gown and gloves, left the room with PPE on, removed gloves at the treatment cart, replaced gloves without hand hygiene, handled gauze, returned to the room, and cleaned the resident’s bloody right toe without performing hand hygiene between tasks. Resident #30 was cognitively intact and had heart failure and diabetes mellitus; orders directed daily wound care for bilateral lower leg blisters. During observed care, RN A placed clean supplies on the bed between the resident’s legs, placed soiled bandages and scissors on the clean barrier, used the same soiled gloves while moving between wounds, left the room with PPE on, removed gloves in the hallway, replaced gloves without hand hygiene, used tongue suppressors to apply cream, and placed soiled scissors in the treatment cart drawer without cleaning or disinfecting them. The DON, administrator, and RN A all stated that hand hygiene, glove changes, clean barriers, and separating wound care tasks were expected during wound care.
Failure to Provide Bed Hold Notices at Hospital Transfer
Penalty
Summary
Facility staff failed to provide written bed hold information to the resident and/or the resident's representative at the time of transfer to the hospital for three sampled residents, Resident #22, Resident #38, and Resident #49. The facility's policy, Bed Hold Policy Guidelines, stated that residents and/or their representative are to be notified of the bed hold policy upon admission, at the time of transfer to the hospital or leave, and at the time of non-covered therapeutic leave. Resident #22 was discharged from the facility to the hospital and later returned on 05/01/25, but the medical record did not contain documentation that a bed hold was issued to the resident or responsible party. Resident #38 was discharged to the hospital and returned on 08/12/25, and the record also lacked documentation of a bed hold notice. Resident #49 was discharged to the hospital and did not have a documented return date, and the medical record did not contain documentation that staff issued a bed hold to the resident or the resident's representative. During interviews, the DON said he/she had started at the facility about a month earlier and was uncertain about the bed hold policy, and the administrator said the discharging nurse was responsible for providing the bed hold policy and obtaining a signature, but was not sure whether this process was currently happening.
Failure to Include Hospice and Catheter Needs in Care Plans
Penalty
Summary
Facility staff failed to develop and implement a comprehensive person-centered care plan for three sampled residents. Resident #2’s admission MDS dated 06/09/25 showed the resident was cognitively intact and receiving hospice services, and the POS dated 06/09/25 included an order for hospice services; however, the care plan dated 09/16/25 did not document hospice care. Resident #30’s quarterly MDS showed the resident was cognitively intact and had an indwelling catheter, but the care plan dated 07/24/25 did not document the catheter. Resident #41’s quarterly MDS showed severe cognitive impairment and no hospice services, while the POS dated 09/10/25 showed an order for hospice services; the care plan dated 06/18/25 did not document hospice care. During interview, the DON stated hospice residents come with their own set of care and that it is important this is care planned. The DON also stated a resident catheter should be care planned and is important for staff to know for infection prevention and care. The administrator stated the care plan coordinator from another home was responsible for care plans and care plan meetings and came to the building two to three times a week, and said he/she had been covering the care plan process for as long as she had been in the building. The administrator was not aware these items were not on the residents’ care plans. The care plan coordinator stated hospice should be included on residents’ care plans, along with any changes to a resident using a catheter, whether the catheter is new or removed.
Failure to Update Care Plans for Changed Resident Conditions
Penalty
Summary
The facility failed to ensure care plans were reviewed and revised when residents’ needs changed for 7 of 13 sampled residents. The facility policy stated care plans should identify each resident’s strengths, needs, goals, and preferences, and be reviewed and revised quarterly, annually, and with any significant change in status. Survey review found that multiple residents had new events or changed conditions documented in progress notes, but their care plans were not updated to reflect those changes. Resident #5 had an annual MDS showing cognitive intactness, wheelchair use, and upper extremity impairments, and progress notes documented unwitnessed falls on 06/01/25 and 06/16/25. The care plan dated 07/10/25 identified fall risk related to a history of falls, but it did not contain new interventions after each fall. Resident #16 had unwitnessed falls on 07/21/25 and 08/11/25, but the care plan last revised 04/09/25 was not updated to reflect the falls or fall interventions. Resident #19 had multiple unwitnessed falls documented on 06/21/25, 07/14/25, 08/16/25, and 08/29/25, and the care plan last revised 04/07/25 was not revised to reflect those falls or interventions. Resident #23 had severe cognitive impairment, one-sided upper and lower extremity impairment, stroke, complete paralysis, and partial weakness, and after an unwitnessed fall on 08/30/25 that caused bruising to the right knee, right ankle, and outside of the right calf, the care plan dated 06/18/25 was not revised. Resident #14 had moderate cognitive impairment and hospice care, and the record showed a DNR order signed by the resident’s representative and a physician order for DNR, but the care plan dated 07/05/25 still listed the resident as full code. Resident #38 had a significant change MDS showing use of an indwelling catheter, but progress notes documented the Foley catheter was removed on 08/31/25 and the care plan dated 08/01/25 was not updated to reflect removal of the catheter. Resident #41 had severe cognitive impairment, used a wheelchair, required moderate assistance with toileting, bathing, dressing, transfers, and had dementia and Parkinson’s disease; progress notes documented unwitnessed falls on 07/30/25, 08/04/25, 08/07/25, 08/22/25, and 09/18/25, but the care plan dated 07/10/25 was not revised to reflect the falls or fall interventions.
Nurse Aide Annual In-Service Training Not Provided
Penalty
Summary
Facility staff failed to ensure CNA G, NA H, and CNA I received a minimum of 12 hours of ongoing annual education, including dementia care and resident abuse prevention training. The facility census was 50.1, and the Resident Matrix dated 09/22/25 showed 16 residents with diagnoses of dementia and/or Alzheimer's disease. Review of the facility's records showed no documentation that CNA G, NA H, or CNA I completed or were provided dementia and/or Alzheimer training. The facility's Nurse Aide Regular In-Service Training policy dated 01/20/24 required in-service training to be sufficient to ensure continuing competence, no less than 12 hours per year, and to include dementia training and resident abuse prevention training, with additional content for nurse aides caring for individuals with cognitive impairments. During interview, the DON stated the facility did not have the required 12-hour trainings set up or implemented for NA staff and said the facility had new ownership in May and had not yet implemented the trainings. The administrator stated he/she expected NA's to receive 12 hours of continued education yearly but was not aware they were not receiving it and said the DON was responsible for the continued education.
Failure to Provide Required RN Coverage
Penalty
Summary
Facility staff failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week, as required by both facility policy and federal regulations. Review of RN staffing assignments revealed that on multiple dates, including 06/11/25, 06/13/25, 06/22/25, 07/04/25, 07/07/25, 07/12/25, and 07/13/25, there was no RN present in the facility for the required duration. The facility census at the time was 46 residents. The facility's own assessment and policy documents confirmed the expectation to have at least one RN on duty for eight hours daily, but this standard was not met on the identified dates. Interviews with the Staffing Coordinator, interim DON, and administrator confirmed awareness of the requirement but revealed that staffing limitations contributed to the deficiency. The Staffing Coordinator stated that only one RN was available aside from the DON, and when the RN was scheduled off, attempts to have the DON cover the shifts were unsuccessful. The interim DON, who assumed the role on 07/14/25, was not aware of the missed RN coverage on the specified dates. The administrator, recently returned from vacation, was also unsure why the RN requirement was not met on those days.
Failure to Post and Maintain Required Nurse Staffing Information
Penalty
Summary
Facility staff failed to post the required daily nurse staffing information, including the facility name, current date, resident census, total number of staff, and actual hours worked by both licensed and unlicensed nursing staff per shift. Observations on multiple occasions confirmed that the nurse staffing information was not posted in a clear and readable format in a prominent place accessible to residents and visitors. Record review revealed that the facility did not maintain daily nurse staffing records for several months, specifically for May, June, and the first half of July. The facility's policy requires this information to be posted daily and retained for at least 18 months. Interviews with the interim DON, staffing coordinator, and administrator revealed a lack of awareness and understanding of the responsibility to post and maintain the required nurse staffing information. The staffing coordinator was not aware it was their responsibility, and the interim DON and administrator were unsure why the records had not been maintained since the new company took over. The facility census at the time was 46.1, and there was no indication that any residents were directly affected or harmed as a result of this deficiency.
Failure to Document Wound Care and Conduct Neurological Assessments
Penalty
Summary
Facility staff failed to maintain professional standards of practice by not documenting wound treatments for a resident, whose wound subsequently became infected. Additionally, staff did not perform necessary neurological assessments for the same resident following a fall. These deficiencies were identified during a review of records and interviews, affecting one resident out of three sampled in a facility with a census of 51.
Deficiencies in TB Screening and Hand Hygiene Practices
Penalty
Summary
The facility staff failed to adhere to applicable laws and regulations regarding Tuberculosis (TB) screening for employees. Specifically, four staff members, including an LPN, a CNA, and two Dietary Aides, were not properly screened for TB as per the facility's policy. The policy required a Mantoux two-step test for all employees and volunteers working eight or more hours per month, with the first step to be completed before resident contact. However, the personnel files of these staff members showed that either the second step of the TB test was not completed or the first step was conducted after they had already started working, indicating a lapse in compliance with the screening protocol. Additionally, the facility staff did not consistently follow proper hand hygiene procedures, particularly in the dietary department. Observations revealed that dietary staff did not wash their hands for the required duration, used the same paper towels to turn off faucets and dry their hands, and failed to perform hand hygiene between glove changes. These actions were contrary to the facility's Glove and Hand Washing Procedures policy, which mandates specific handwashing techniques and glove usage to prevent cross-contamination. Interviews with dietary staff and the Certified Dietary Manager confirmed a lack of adherence to these procedures, with staff admitting to not following the correct handwashing steps due to oversight or being in a hurry. The administrator acknowledged the deficiencies in both TB screening and hand hygiene practices. The responsibility for TB testing had been assigned to a new MDS nurse, who had not yet been instructed to complete the screenings. The administrator was unaware of the incomplete TB tests until the survey and attributed the oversight to the departure of the previous MDS nurse. Similarly, the administrator and Certified Dietary Manager confirmed that staff were trained on proper hand hygiene procedures upon hire, but the observed practices indicated a gap between training and implementation.
Deficiency in Resident Fund Management and Statement Distribution
Penalty
Summary
The facility failed to maintain an accurate accounting system for resident funds and did not provide quarterly bank statements to residents from March 2024 to July 2024. The facility's policy requires that transactions be entered daily and resident statements be sent quarterly. However, the facility's bank statements lacked monthly reconciliation, and no quarterly statements were sent out in 2024. This issue affected 25 residents out of a census of 54. Interviews revealed that the facility's accounting records were not reconciled monthly, and residents did not receive their quarterly bank statements due to a transition in staff. The former Business Office Manager (BOM) retired in February 2024, and the Corporate Accounts Receivable (AR) and Corporate BOM were responsible for these tasks. The Corporate AR admitted that the accounts were not reconciled monthly due to the transition, and the Corporate BOM, who took over a month ago, sent the second quarter statements late. The first quarter statements' status was uncertain, as the current Corporate BOM was not responsible at that time.
Failure to Refund Discharged Residents' Personal Funds
Penalty
Summary
Facility staff failed to provide refunds of personal funds to six residents who were discharged from the facility. The facility's policy requires that upon written request, the facility must hold, safeguard, manage, and account for the resident's personal funds. However, a review of the facility's Account Receivable Aging report showed that these residents had personal funds held in the facility's operating account, with balances ranging from $78.80 to $6922.04, despite being discharged. The facility census was 54. Interviews revealed that the facility had not had a Business Office Manager (BOM) since February, and the corporate team was responsible for bank reconciliations and Aging Reports. The administrator was unaware of the outstanding balances for discharged residents, as the corporate team assumed responsibility after the previous BOM retired. The Corporate Accounts Receivable (AR) acknowledged the oversight, stating that the AR report should be reviewed monthly for outstanding balances and credits, which had not been done due to the transition. The corporate AR is currently working on refunding the outstanding balances.
Failure to Complete Pre-Employment Screenings
Penalty
Summary
The facility failed to complete necessary pre-employment screenings for six out of ten sampled employees, which included a housekeeper, dietary aides, a licensed practical nurse, and certified nursing aides. The screenings that were not completed included the Criminal Background Check (CBC), Employee Disqualification List (EDL) verification, Family Care Safety Registry (FCSR), and Certified Nursing Aide (CNA) Registry verification. The facility's policy on recruitment and hiring, revised in March 2024, mandates that all pre-hire screenings be processed within one or two business days of receiving documentation from the hiring manager. However, the policy lacked specific instructions for checking the CNA registry, contributing to the oversight. The deficiency was further compounded by a change in personnel responsible for conducting these screenings. The former Business Office Manager, who was responsible for completing pre-employment screenings, retired in February, and the facility had not filled the position since. Consequently, the responsibility was transferred to the corporate HR department, which was managed by a new HR person who had only been with the company for one month. The administrator was unaware that the screenings had not been completed and could not provide an explanation for the oversight.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility staff failed to develop and implement comprehensive person-centered care plans for four residents, leading to deficiencies in care. Resident #5, who had cognitive impairment and was receiving hospice services, did not have hospice services included in their care plan despite having a physician's order for such services. This oversight was evident when hospice staff visited the resident, yet there was no direction in the care plan regarding hospice care. Resident #31's care plan contained conflicting information regarding their code status. Although the resident was assessed as cognitively intact and had a physician's order not to perform CPR, the care plan inaccurately documented the resident as both a full code and a do-not-resuscitate (DNR) status. This inconsistency could lead to confusion among staff regarding the appropriate response in an emergency situation. Resident #44, who had severe cognitive impairment and pressure ulcers, was ordered to wear moon boots for pressure relief. However, the care plan did not include instructions for the use of moon boots, and observations showed the resident was frequently without them. Additionally, Resident #48, with severe cognitive impairment and a history of wandering, had multiple care needs, including hospice services, a wander guard, and monitoring for weight loss. Yet, the care plan lacked directions for these critical aspects of care, as evidenced by the resident's wandering behavior and significant weight loss over time.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near New Florence
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aspire Senior Living Jonesburg | 9.5 mi | ★★★★★ | 19 | 0 |
| Wellsville Health Care Center | 12.3 mi | ★★★★★ | 1 | 0 |
| Stonebridge Hermann | 15.3 mi | ★★★★★ | 0 | 0 |
| Warrenton Manor | 18.9 mi | ★★★★★ | 7 | 0 |
| New Haven Care Center | 24.9 mi | ★★★★★ | 0 | 0 |
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