Aspire at Evans

In the surveyor’s words

From the most serious findings on record at Aspire at Evans, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 20, 2026

  Based on observation, review of facility policy and procedures, record review and staff interviews, the facility failed to provide adequate supervision and implement appropriate resident centered interventions to prevent avoidable accidents for 1 (Resident #999) of 3 residents reviewed who were identified as being at risk for falls and sustained multiple falls at the facility, including falls with injuries.The findings included:Review of the facility provided policy N-1259 Fall Management effective 11/30/14 (revised 7/29/19) documented, Residents are evaluated for fall risk. Patient centered interventions are initiated, based on resident risk . […]

• Actual harm, isolatedF600Jul 7, 2025

  Based on record review, review of facility policy and procedures, staff and resident interviews, the facility failed to protect the resident's right to be free from physical, and verbal abuse for 1(Resident #999) of 3 residents reviewed for abuse.The findings included: Review of the facility policy N-1265 Abuse, Neglect, Exploitation and Misappropriation effective 11/30/14 (revised 11/16/22) documented It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse . Employees of the center are charged with a continuing obligation to treat residents so they are free from abuse . No employee may at any time commit an act of physical, psychological, or emotional abuse . against any resident . […]

• Actual harm, isolatedF600Jun 12, 2025

  Based on observation, record review and interview, the facility failed to ensure residents were free from abuse, including but not limited to physical restraint not required to treat the resident's medical symptoms for 1 (Resident #1) of 1 resident reviewed for physical restraint. The findings included: Facility policy titled Abuse, Neglect, Exploitation & Misappropriation Revision date 11/16/2022 indicated Abuse is the willful infliction of injury. Willful, as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Review of the clinical record revealed Resident #1 was re-admitted to the facility on [DATE]. […]

• Actual harm, isolatedF689Aug 21, 2024

  Based on observation, record review, review of facility's policy and procedure, staff, and family interview the facility failed to implement a systemic approach to identify risk factors and implement appropriate supervision and interventions to prevent avoidable falls with serious injuries for 3 (Resident #10, #69 and #30) of 5 residents sampled with falls or fall related injuries. The findings included: The facility policy N-1259 Fall Management documented Residents are evaluated for fall risk. Patient centered interventions are initiated based on resident risk. A fall refers to unintentionally coming to rest on the ground floor or other lower level but not as the result of an overwhelming external force (e.g. resident pushes another resident). […]

• No harm, potential for more than minimal, widespreadF812Aug 21, 2024

  Based on observation, staff interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in long term care facilities in a safe and sanitary manner. The findings included: The facility policy titled Food Storage: Cold Foods Policy last revised 2/2023 states all time/temperature control for safety foods, frozen and refrigerated, will be appropriately stored in accordance with the guidelines of the FDA Food Code. Procedures include: All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. The Equipment Policy provided by facility stated, All foodservice equipment will be clean, sanitary, and in proper working order. […]