Aspen Health and Rehab

Inspectors wroteBased on record review and interview, the facility failed to develop a resident's care plan for dementia for 1 (#14) of 23 sampled residents reviewed for dementia.

Inspectors wroteBased on record review and interview, the facility failed to ensure grievances were filed without fear of reprisal for 1 (#3) of 3 sampled residents who were reviewed for grievances. The administrator identified 93 residents resided at the facility.

Inspectors wroteBased on observation and interview, the facility failed to maintain comfortable sound levels in halls, by resident rooms, and resident common areas of the facility. The facility alphabetical room roster showed there were 100 residents. On 06/04/25 at 4:30 p.m., several children were observed in the second floor billiard room, playing with the billiard balls on the billiard table by slamming the billiard balls against one another. The children's voices were loud. On 06/04/25 at 6:00 p.m., two children were observed entering the elevator. The children appeared to be under the age of 10 and each wore the walkie-talkie style headset the staff wore for inter-facility communication. On 06/04/25 at 6:15 p.m., a group of children stood in the first floor hallway, near an open office door. [...]

Inspectors wroteBased on record review and interview, facility staff failed to follow the plan of care for 1 (#4) of 6 residents whose clinical records were reviewed. The facility alphabetical room roster showed there were 100 residents.

Inspectors wroteOn 04/01/25 at 9:18 a.m., an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure residents were free from abuse and neglect. A nurse's statement, dated 03/27/25 at 11:15 p.m., showed Resident #1 reported to RN #1, CNA #1 on the evening shift was mean and hurt them. Resident #1 reported CNA #1 threw them on the bed hard enough to make the bed move and hurt them every time CNA #1 was their aide. Resident #1 reported CNA #1 had been hurting them for a while and they were afraid to report it because they were afraid CNA #1 would get meaner. RN #1 documented Resident #1 broke down into tears crying and asked to keep CNA #1 out of their room. On 03/31/25 at 11:39 a.m., Resident #1 stated the incident on 03/27/25 made them feel abused in a way. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure medication orders from the physician were implemented for 2 (#2 and #4) and failed to ensure daily weights were obtained as ordered by the physician for 1 (#4) of 3 sampled residents who were reviewed for quality of care. The ADON identified 113 residents who received medications and 20 residents who were ordered daily weights.

Inspectors wroteBased on record review and interview, the facility failed to ensure labs were completed as ordered by the physician for 2 (#2 and #6) of 3 sampled residents whose labs were reviewed. The ADON identified 113 residents who resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure allegations of abuse were reported to the Oklahoma State Department of Health within 2 hours for 1 (#1) of 3 sampled residents who were reviewed for abuse. The administrator identified 113 residents who resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure assessments were accurate for 1 (#3) of 7 sampled residents whose assessments were reviewed. The administrator identified 113 residents who resided in the facility.

Inspectors wroteBased on observation and interview, the facility failed to secure protected health information for six (Resident #206, #310, #315, #316, and Resident #318) of six residents whose protected health information was observed in a bin secured to the wall outside of a social service office. The administrator identified 113 residents in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure interventions were developed to treat limited range of motion for one (#27) of one sampled residents who were reviewed for limited range of motion. The DON identified 34 residents who had limited range of motion.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were monitored for side effects from psychotropic medications for five (#5, 27, 39, 52, and #86) of five sampled residents who were reviewed for unnecessary medications and failed to implement pharmacy recommendations as ordered by the physician for one (#5) of five sampled residents who were reviewed for unnecessary medications. The DON identified 50 residents who received psychotropic medications.

Inspectors wroteBased on observation, record review, and interview, the facility failed to assess a resident for continued need of an indwelling urinary catheter for one (#312) of four residents who were reviewed for catheters. The Administrator identified 12 residents with indwelling urinary catheters.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure: a. The temperature of the second-floor medication room was documented. b. The temperature of the second-floor medication refrigerator was documented. C. Treatment/medication carts were locked when unattended. The administrator reported the census was 120.

Inspectors wroteBased on observation and interview, the facility failed to ensure garbage containers in the food preparation area were covered with lids. The DM identified 112 residents who received services from the kitchen.

Inspectors wroteBased on record review and interview, the facility failed to follow physician's orders when administering a medication for one (#1) of three sampled residents whose medication administration records were reviewed. The Detailed Census Report, dated 09/06/23, documented a census of 104 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or resident representatives were invited to and participated in their plan of care conference for one (#13) of one sampled resident reviewed for participation in care plan conferences. The Resident Census and Conditions of Residents report, dated 05/22/23, documented 88 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure medications were administered as ordered for three (#16, 33, and #42) of 13 residents observed during medication administration. This resulted in a medication error rate of 12%. The administrator identified 88 residents who received medications in the facility.