Aspen Health and Wellness

Inspectors wroteThe facility identified a census of 58 residents. The sample included 14 residents. Based on observation, record review, and interviews, the facility failed to ensure sufficient staffing to ensure adequate resident care and call light response. This placed the facility residents at risk for a decline and inadequate resident care being completed. Findings Included: - A review of the facility's Payroll-Based Journal (PBJ -Staffing Data Report) from 04/01/22 through 03/31/25 indicated the facility triggered for One Star Staffing for Fiscal Year (FY) 2024 Quarter Three 04/01/24-06/30/24), FY 2024 Quarter Four (07/01/24-09/30/24), FY 2025 Quarter One (10/01/24-12/31/24), and FY 2025 Quarter Two (01/01/25-03/31/25). The Resident Council Minutes for 04/14/25 noted concerns that residents were not getting their showers completed on their assigned shower days. [...]

Inspectors wroteThe facility identified a census of 58 residents. The facility identified fifteen residents on Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record reviews, observations, and interviews, the facility failed to ensure trash was stored and contained properly. The facility further failed to ensure that catheter bags were kept off the floor. The facility further failed to ensure that respiratory equipment, such as a BIPAP (a type of noninvasive ventilation used to assist breathing) mask, a nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) mask, and a nasal cannula, was stored in a sanitary manner. These deficient practices placed the residents at risk for infectious diseases.

Inspectors wroteThe facility identified a census of 58 residents. The sample included 14 residents. Based on observation, record review, and interviews, the facility failed to develop and implement the core elements of antibiotic stewardship to ensure an effective infection prevention and control program, including antibiotic stewardship for the residents of the facility.

Inspectors wroteThe facility reported a census of 58. Based on observations, record reviews, and interviews, the facility failed to resolve recurring issues reported by the Resident Council. This deficient practice placed the residents at risk for decreased psychosocial well-being. Findings Included: - A review of the facility's Resident Council Minutes from 06/24 through 06/25 indicated the council had recurring concerns with the food choices, menus, temperatures, and availability. The minutes also noted concerns related to maintaining and cleaning the shower rooms. The Resident Council Minutes for 07/22/24 noted under new business concerns, facility staff were not following the resident bathing schedules. The minutes indicated staff would walk into the room, turn off the call light, and exit the room. [...]

Inspectors wroteThe facility identified a census of 58 residents. The sample included 14 residents. Based on observation, record review, and interviews, the facility failed to provide direct, interactive activities based on resident preferences for the residents on weekends. This deficient practice placed the affected residents at risk for decreased psychosocial well-being, boredom, and isolation. Findings Included: - A review of the facility's Activity Calendars for March 2024, April 2025, May 2025, and June 2025 was completed. A review of Sunday for the majority of each month revealed the residents were only offered a self-led activity packet for an activity. On 06/25/24 at 02:00 PM, the facility's Resident Council reported that the weekend activities were inconsistent with what was scheduled. The council reported on Sunday's the residents did not always receive staff-led activities. [...]

Inspectors wrote- R12's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), muscle weakness, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and need for assistance with personal hygiene. The Significant Change Minimum Data Set (MDS) dated 08/07/24 documented R12 moderately impaired cognition. The MDS documented R12 had an indwelling catheter. The MDS documented R12 was dependent on staff assistance for toileting and bathing. The MDS documented R12 had one non-injury fall during the observation period. [...]

Inspectors wrote- R12's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), muscle weakness, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and need for assistance with personal hygiene. The Significant Change Minimum Data Set (MDS) dated 08/07/24 documented R12 moderately impaired cognition. The MDS documented R12 had an indwelling catheter. The MDS documented R12 was dependent on staff assistance for toileting and bathing. The MDS documented R12 had one non-injury fall during the observation period. [...]

Inspectors wroteThe facility identified a census of 58 residents. The sample included 14 residents, with 14 residents. Based on observation, record review, and interviews, the facility failed to include Resident (R) 34 or her representative in the development and planning of the resident's care plan. This deficient practice placed R34 at risk of impaired care and decreased autonomy.

Inspectors wroteThe facility identified a census of 58 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 3 had been assessed for the ability to self-administer her physician-ordered Voltaren gel (a pain-relieving gel). This placed R3 at risk of unsafe medication administration and adverse effects.

Inspectors wroteThe facility identified a census of 58 residents. The sample included 14 residents. Three residents were sampled for reasonable accommodations of needs. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 13, R12, and R57 call lights were within their reach. This deficient practice left R13, R12, and R57 vulnerable to unmet care needs due to the inability to call for staff assistance. Findings Included: - On 06/24/25 at 07:00 AM, an inspection of R13's (vulnerable resident unable to self-transfer) laid on her bed, R13's call light lay on the over-the-bed table. R13's over-the-bed table was pushed away from her. She was unable to reach her call light. On 06/24/25 at 07:40 AM, R12 (a cognitively impaired, unable to transfer herself) was asleep on the bed with her lower extremities off to the left side of the bed. [...]

Inspectors wroteThe facility identified a census of 58 residents. The sample included 14 residents, with three residents reviewed for hospitalization and/or discharge. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 19 and his representative were provided with a bed hold policy that included the facility's per diem rate to hold a bed. The facility failed to ensure R19, and his representative was provided a written notification of transfer upon his transfer to the hospital. The facility failed to ensure that a discharge summary and a recapitulation of stay were completed upon R61's discharge from the facility. This placed R19 and R61 at risk of miscommunication between the facility and the resident's representative, and the possible missed opportunity for healthcare services.

Inspectors wroteThe facility identified a census of 58 residents. The sample included 14 residents, with two residents reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to identify a significant change in the physical condition and complete a comprehensive Significant Change Minimum Data Set (MDS) for Resident (R) 34 with the discharge from hospice services. This deficient practice placed R34 at risk for unidentified care needs.

Inspectors wroteThe facility identified a census of 58 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 3's Care Plan had been revised to direct staff that she was safe to self-administer her physician-ordered Voltaren gel (a pain-relieving gel). This placed R3 at risk of unsafe medication administration and adverse effects.

Inspectors wrote- R12's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), muscle weakness, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and need for assistance with personal hygiene. The Significant Change Minimum Data Set (MDS) dated 08/07/24 documented R12 moderately impaired cognition. The MDS documented R12 had an indwelling catheter. The MDS documented R12 was dependent on staff assistance for toileting and bathing. The MDS documented R12 had one non-injury fall during the observation period. [...]

Inspectors wroteThe facility identified a census of 58 residents. The sample included 14 residents, with one resident reviewed for quality of care. Based on observation, record review, and interviews, the facility failed to follow a physician's order for weights to monitor for edema and fluid overload for Resident (R) 52. This deficient practice placed R52 at risk for delay in treatment related to fluid overload and untreated illness.

Inspectors wroteThe facility identified a census of 58 residents. The sample included 14 residents, with three residents reviewed for treatment/services to prevent/heal pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure pressure-reducing measures were placed on Resident (R)13. This placed R13 at increased risk for pressure ulcer development. Findings Included: [...]

Inspectors wroteThe facility identified a census of 58 residents. The sample included 14 residents, with two residents reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 25's Bilevel positive airway pressure (noninvasive ventilation used to assist breathing) mask, nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) mask and nasal cannula (a medical device that delivers supplemental oxygen or other therapeutic gases to a patient through two small, flexible tubes inserted into the nostrils) was stored in a sanitary manner. This placed R25 at an increased risk for respiratory infection and complications.

Inspectors wroteThe facility identified a census of 58 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to ensure the Consulting Pharmacists (CP) identified when staff administered R52's midodrine (a medication used to treat low blood pressure) outside the physician-ordered parameters. This placed R52 at risk for unnecessary medication administration and related complications.

Inspectors wrote- R52's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), hypotension (low blood pressure), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), muscle weakness, unsteady on her feet, and the need for assistance with personal care. The admission Minimum Data Set (MDS) dated 07/12/24 documented a Brief Interview of Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. [...]

Inspectors wrote- R34's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), dysphagia (swallowing difficulty), and aphasia (a condition with disordered or absent language function). The Annual Minimum Data Set (MDS) dated 02/12/25 documented R34 had severely impaired cognition. The MDS documented R34 had received hospice services during the observation period. The Quarterly MDS dated 05/13/25 documented R34 had severely impaired cognition. The MDS documented R34 had received hospice services during the observation period. R34's Cognitive Loss/Dementia Care Area Assessment (CAA), dated 02/17/25, documented she had received hospice services for additional supportive care. [...]

Inspectors wroteThe facility identified a census of 62 residents. The sample included three residents reviewed for weight loss. Based on record review and interviews, the facility failed to implement interventions to prevent further weight loss for Resident (R) 1 after she experienced a significant weight loss, and the facility implemented an initial intervention in September 2024. R1 continued to experience significant weight loss and Consultant GG followed R1 but did not recommend further interventions to prevent weight loss and the facility failed to implement further weight loss prevention interventions. This deficient practice resulted in a significant weight loss of 25.6% for R1.

Inspectors wroteThe facility identified a census of 83 residents. The sample included three residents. Based on observation, record review, and interview, the facility failed to prevent an incident of resident-to-resident sexual abuse when Resident (R) 1, who had a history of inappropriate sexual behaviors with a recent escalation, exposed his genitals to R2, a cognitively impaired resident unable to consent. This deficient practice resulted in a negative reaction from R2 and placed the residents at risk for impaired psychosocial well-being including fear and embarrassment, and risk for ongoing sexual abuse. Findings Included: [...]

Inspectors wroteThe facility identified a census of 77 residents. Based on record review and interviews, the facility failed to ensure an agency nurse, Licensed Nurse (LN) G, had the required effective communication education. This deficient practice placed residents at risk for impaired communication with LN G.

Inspectors wroteThe facility identified a census of 77 residents. Based on record review and interviews, the facility failed to ensure an agency nurse, Licensed Nurse (LN) G, had the required resident rights education. This deficient practice placed residents at risk for impaired resident rights.

Inspectors wroteThe facility identified a census of 79 residents. The sample included three residents with two reviewed for accidents. Based on observation, record review, and interviews, the facility failed to ensure Resident can 1 remained free from accidents when Certified Nurse Aide can (CNA) M propelled R1 down the hallway in her wheelchair, without a foot pedal for her right leg/foot. This caused R1's foot to get stuck under the wheelchair and resulted in a fracture (broken bone) to her right leg. The facility further failed to prevent accidents for R2 when CNA N failed to utilize two people with a Hoyer lift (total body mechanical lift) transfer which resulted in R2 slipping out of the lift sling and landing on the floor. This deficient practice placed R2 at risk for injuries and physical complications.

Inspectors wroteThe facility had a census of 75 residents. The sample included 18 residents. Based on record review and interview the facility failed to ensure five of five nurse aides, reviewed for regular in-service education, completed an annual performance review. This placed the residents at risk for unskilled care.

Inspectors wroteThe facility had a census of 75 residents. Based on observation, interview, and record review, the facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing.

Inspectors wroteThe facility had a census of 75 residents. The sample included 18 residents. Based on record review and interview, the facility failed to ensure the required committee members attended the Quality Assurance Performance Improvement (QAPI) Committee quarterly meetings. This failure placed the residents who resided in the facility at risk for decreased quality of care.

Inspectors wrote- On 10/17/23 at 08:35 AM, observation revealed Licensed Nurse (LN) H performed wound care for Resident (R) 5. He placed wound care items on a clean field on the bedside table. LN H provided urine incontinence care for R5 and after placing a new brief on R5, he changed his gloves without washing his hands. The pressure wound to R5's coccyx (triangular area at the base of the spine) was without a dressing; LN H cleansed the wound and, without washing hands or changing gloves, applied Skin-prep (liquid skin protectant), Santyl (a prescription enzyme used to help break up and remove dead skin and tissue of a wound), a collagen (protein derived wound treatment used to promote wound healing) patch, then applied a bordered foam dressing. On 10/18/23 at 09:24 AM, LN H verified he should have washed his hands between removing the soiled dressing and before applying the clean wound dressings. [...]

Inspectors wroteThe facility had a census of 75 residents. The sample included 18 residents. Based on observation, interview and record review, the facility failed to employ a designated Infection Preventionist (IP) as required. This placed the residents in the facility at increased risk for infection and related complications.

Inspectors wroteThe facility had a census of 75 residents. Based on record review and interview, the facility failed to ensure three of five Certified Nurse Aides (CNAs) completed their required 12-hour annual in-services. This placed the residents at risk for receiving unskilled care.

Inspectors wroteThe facility had a census of 75 residents. The sample included 18 residents. Based on observation, and interview the facility failed to maintain a clean, comfortable, home like environment when the lights in the dining room were nonfunctioning, the light fixtures contained dead insects, and the dining chairs were stained and had food particles. This placed the residents at risk for decreased comfort and impaired psychosocial wellbeing.

Inspectors wroteThe facility had a census of 75 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to discuss with the resident council how to file a grievance regarding their care and treatment in the facility. This deficient practice placed the residents in the facility at risk for unresolved resident concerns and decreased quality of life.

Inspectors wroteThe facility had a census of 75 residents. Based on observation, interview, and record review the facility failed to label insulin (hormone that lowers the level of glucose in the blood) when opened and dispose of expired medications in a timely manner. This deficient practice placed residents of the facility at risk to receive expired or ineffective medications.

Inspectors wroteThe facility had a census of 75 residents. Based on observation, interview, and record review the facility failed to store foods and monitor refrigeration temperatures for the resident food storage in the nourishment rooms in accord with professional standards for food safety. This deficient practice placed the residents who received food from or stored their food in the nourishment refrigerators on two of two resident halls at risk for food borne illness.

Inspectors wroteThe facility had a census of 75 residents. The sample included 18 residents. Based on observation, record review, and interview the facility failed to provide adequate lighting in the main dining room. This placed the residents at risk for impaired quality of life. Findings Included: - On 10/16/23 at 11:59 AM, observation in the main dining room revealed the following: The fluorescent light, approximately three feet (ft) long by 18 inches wide, had nonfunctioning bulbs, on the ceiling above the dining room door where the STOP sign was posted. Two ceiling fluorescent light fixtures, close to the kitchen entrance. had nonfunctioning light bulbs. [...]

Inspectors wroteThe facility had a census of 75 residents. The sample included 18 residents. Based on observation and record review the facility failed to provide a safe and sanitary environment, when six fluorescent ceiling light fixtures had numerous bugs, the sink counter top edge had missing pieces of laminate in the main dining room, and chairs in the rehabilitation dining room had stains and food particles three days of the onsite survey. This placed the residents at risk for decreased quality of care and life.

Inspectors wroteThe facility had a census of 75 residents. The sample included 18 residents with one reviewed for hospitalization. Based on observation, interview, and record review the facility failed to notify the State Long Term Care Ombudsman (resident advocate) of Resident (R)26's discharges to a hospital in July 2023 and in September 2023. This deficient practice placed R26 at risk for decreased oversight of transfers.

Inspectors wroteThe facility had a census of 75 residents. The sample included 18 residents with one reviewed for hospitalization. Based on observation, interview, and record review the facility failed to provide a Bed Hold Notice to Resident (R) 26 upon discharge to a hospital in July 2023 and in September 2023. This deficient practice placed R26 at risk of making uninformed decisions regarding her care.

Inspectors wroteThe facility had a census of 75 residents. The sample included 18 residents with one reviewed for smoking safety. Based on observation, interview, and record review the facility failed to develop a baseline care plan to include Resident (R) 127's smoking. This deficient practice placed R127 at risk for impaired safety due to uncommunicated care needs.

Inspectors wroteThe facility had a census of 75 residents. The sample included 18 residents with one reviewed for smoking safety. Based on observation, interview, and record review the facility failed to assess Resident (R) 127 for safety while smoking. This deficient practice placed R127 at risk for accidents while smoking.

Inspectors wroteThe facility had a census of 75 residents. The sample included 18 residents with one reviewed for hydration. Based on observation, interview, and record review the facility failed to monitor fluid intake for Resident (R) 41, as ordered by the physician. This deficient practice placed R41 at risk for fluid overload.

Inspectors wroteThe facility had a census of 75 residents. The sample included 18 residents with five reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to follow the consultant pharmacist's recommendation and obtain a specific approved indication for the use of Seroquel (antipsychotic medication used to treat psychosis and other mental emotional conditions). This deficient practice placed Resident (R)60 at risk for inappropriate use of antipsychotic medication.

Inspectors wroteThe facility had a census of 75 residents. The sample included 18 residents with one reviewed for psychotropic drug use. Based on observation, interview, and record review the facility failed to ensure an appropriate indication, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat mental disorder characterized by a gross impairment in reality testing) for Resident (R)60, who had a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). This placed the resident at risk for unnecessary psychotropic (alters perception, mood, consciousness, cognition, or behavior) medications and related complications.

Inspectors wroteThe facility had a census of 75 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to ensure the daily staff nursing hours were posted for three of four of the survey onsite days.

Inspectors wrote- R18's Physician's Order Sheet, dated 11/23/21, recorded the diagnoses of bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). R18's Significant Change Minimum Data Set (MDS), dated [DATE], recorded R18 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS recorded she required extensive staff assistance with personal hygiene and bathing. The Activities of Daily Living (ADL) Care Plan, dated 11/04/21, directed R18 required one staff to provide the resident assistance with bathing two times a week. R18's Bathing Report and bath sheets documented the resident received a shower/bath on Wednesday evening shift and Saturday day shift. [...]

Inspectors wroteThe facility had a census of 71 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to label Resident (R) 20, R14, R66, R44, R25, R27, and R56s insulin (hormone which allows cells throughout the body to uptake glucose) pens and vial with the date opened and expiration date, and discard expired stock medications on two of four medication carts. This placed these residents at risk for ineffective medications.

Inspectors wroteThe facility had a census of 71 residents. The sample included 18 residents, with three reviewed for Beneficiary Notices. Based on record review and interview, the facility failed to provide two sampled residents, Resident (R) 9, and R44 (or their representative) the completed Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) Form 10055. This placed the residents at risk to make uninformed decisions about their skilled services.

Inspectors wroteThe facility had a census of 71 residents. The sample included 18 residents with three reviewed for pressure ulcers. Based on observation, record review and interview, the facility failed to provide a low air loss (LAL) mattress (designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) as ordered by the physician for one of three sampled residents, Resident (R) 61. This placed R61 at risk to worsen her current pressure ulcer or develop more skin issues.

Inspectors wroteThe facility had a census of 71 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to obtain respiratory assessments prior to and after the development of COVID-19 (a highly contagious respiratory condition) for Resident (R)37, placing the resident at risk for delayed identification and treatment for a decline in condition. Findings Included: - R37's Physician Order Sheet (POS), dated 10/05/21, documented diagnoses of rhabdomyolysis (a breakdown of muscle tissue breakdown resulting in the release of a protein into the blood that can damage the kidneys), chronic pancreatitis (inflammation of organ that helps digestion and regulates blood sugar), heart failure, atrial fibrillation (rapid, irregular heart beat ), cardiomyopathy (disease of heart muscle), dehydration, and disorder of the kidney. [...]

Inspectors wroteThe facility had a census of 71 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to obtain and administer blood pressure medication for one of five residents reviewed for medication use, Resident (R) 55, placing the resident at risk for elevated blood pressure and/or chest pain.

Inspectors wroteThe facility had a census of 71 residents. The sample included 18 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, failed to complete a pharmacist recommended GDR (gradual dose reduction) for psychotropic medications (medications that affect a person's mental state) for Resident (R) 2, and ensure a stop date or rationale for extended use for PRN (as needed) psychotropic (medications that affect a person's mental state) medication for R18. This placed R2 and R18 at risk to receive unnecessary psychotropic medications and adverse medication side effects.

Inspectors wroteThe facility had a census of 71 residents. The sample included 18 residents with one reviewed for hospice (a type of health care that focused on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R) 6. This placed R6 at risk for inappropriate end of life cares.

Inspectors wroteThe facility had a census of 71 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to ensure urinary catheter tubing did not touch the floor for one sampled resident, Resident (R) 2. This placed R2 at risk for urinary tract infections (UTI).