Aspen Hill Rehabiliation & Healthcare Center

Inspectors wroteBased on observations, record review, policy review and interview, the facility failed to ensure dental services were provided for two Residents (#105 and #20) out of a total sample of 27 Residents. Specifically, the facility failed to:1. For Resident #105, the facility failed to acknowledge and implement the dentist's continued recommendations for the extractions of seven teeth.2. For Resident #20, the facility failed to ensure dental services were provided after being assessed by the contracted dentist on 10/22/2024, with recommendations.

Inspectors wroteBased on record review and interview, the facility failed to obtain the necessary psychotropic consent for one Resident (#44) out of a total sample of 27 residents.

Inspectors wroteBased on record review and interviews, the facility failed to ensure an advanced directive was current and not expired for one Resident (#20) out of a total sample of 27 residents. Specifically, for Resident #20 the facility failed to ensure the [NAME] Guardianship and Probate Court Treatment Plan (a guardian appointed by a judge in probate court who is responsible for making decisions for an individual after a judge has decided they are not competent to make their own informed choices, including treatment with antipsychotic medication) was reviewed prior to the court appointed [NAME] Treatment Plan expired.

Inspectors wroteBased on observations, record review and interview, the facility failed to ensure that activities of daily living were provided for one Resident (#79) out of a total sample of 27 Residents. Specifically, for Resident #79, the facility failed to ensure that the Resident received 1:1 (one to one) supervision while eating breakfast and that the plan of care was followed while Resident #79 was eating breakfast.

Inspectors wroteBased on observation record review and interview, the facility failed to ensure staff maintained an accurate medical record for one Resident (#16) out of a total sample of 27 residents. Specifically, the facility failed to accurately document and transcribe Resident #16's supplemental oxygen flow rate.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #3), whose comprehensive plan of care and Care [NAME] (a summary of the resident's care needs, utilized by Certified Nurse Aides) indicated he/she required staff assistance with ambulation, the Facility failed to ensure staff consistently implemented and followed interventions related to ambulation, per his/her plan of care. On 02/11/25, Certified Nurse Aide (CNA) #2 saw Resident #3 ambulating by him/herself, and although she thought he/she required staff supervision with ambulation, CNA #2 did not provide him/her with supervision or assistance (per the plan of care) with ambulation. Resident #3 ambulated unassisted to his/her room, fell, was found a short time afterward on the floor, and was bleeding from a cut on his/her left eyebrow. [...]

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #3), who was assessed by nursing as being at risk for falls, the Facility failed to ensure he/she was provided with the necessary level of staff assistance to prevent an incident resulting in an injury. On 02/11/25, Certified Nurse Aide #2, who was familiar with and had provided care to Resident #3, observed him/her ambulating alone, but did not provide or get another staff member to assist or supervise him/her. Resident #3 was found a short time later on the floor in his/her room, was bleeding from a cut on his/her left eyebrow, was transferred to the Hospital Emergency Department (ED) and required three sutures to close the head wound.

Inspectors wroteBased on record review and interview, the facility failed to keep one Resident (#1) free from abuse out of a total sample of 28 residents. Specifically, an allegation of abuse was made by Resident #95 and filed as a grievance, subsequently allowing the accused certified nursing aide to continue working, which led to the physical abuse of Resident #1.

Inspectors wroteBased on record review and interview, the facility failed to 1a. investigate an allegation of potential abuse for one Resident (#95), which 1b. failed to keep Resident (#1) free from abuse, out of a total sample of 28 residents. Specifically, Resident #95 reported to staff having been rough handled by a certified nursing aide. The report was not thoroughly investigated, which allowed the accused certified nursing aide to continue working, and eventually abuse Resident #1.

Inspectors wroteBased on observations, record review and interviews, the facility failed to meet professional standards of practice for four Residents (#111, #106, #71, and #112) out of a total of sample of 28 residents. Specifically; 1. For Resident #111, the facility failed to ensure nursing implemented compression stockings as ordered by the physician. 2. For Resident #106 the facility failed to ensure nursing clarified a physician's order for g-tube flushes (two different flush orders) and failed to ensure Resident #106's feeding tube pump was set to the correct flush settings. 3. For Resident #71 the facility failed to ensure Resident #71's diet was least restrictive. 4. For Resident #112 the facility failed to obtain weights as ordered by the physician.

Inspectors wroteBased on record review and interview the facility failed to ensure sufficient staffing to assure residents attain or maintain the highest practicable physical, mental, and psychosocial well being. Specifically, the facility failed to have sufficient staffing on the weekends as indicated on the payroll-based journal report submitted to The Centers of Medicare and Medicaid (CMS) for FY (Fiscal Year) Quarter 4, 2024.

Inspectors wroteBased on observations, and interviews, the facility failed to ensure 1.) medications were labeled, and dated once opened, according to manufacturer's guidelines in two out of three medication carts sampled, and 2.) ensure medications were stored in locked compartments on one nursing unit.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that recommended specialist appointments were scheduled for three Residents (#32, #28, and #93), who had recommendations for an evaluation for cataract surgery from the consulting eye doctor, out of a total sample of 28 residents.

Inspectors wroteBased on record review and interview the facility failed to ensure accurate documentation in the medical record for four Residents (#88, #47, #418, #89) out of a total sample of 28 residents. Specifically: 1. For Resident #88 nursing documented in the Treatment Administration Record (TAR) that a. oxygen (O2) was running at the correct setting, when it was not, b. that the O2 tubing was changed as ordered and c. that foam ear protectors were in place as ordered. 2. For Resident #47 the facility failed to ensure his/her risperidone (antipsychotic medication) order included an associated diagnosis as part of the physician's order. 3. For Resident #418 the facility failed to document accurately in the Medication Administration Record (MAR) when the nurse documented adminstraion of Insulin was given when it was not. 4. [...]

Inspectors wroteBased on record review and interview, the facility failed to implement their abuse policy by failing to investigate an allegation of abuse from one Resident (#95), which led to the abuse of another resident by the same certified nursing aide, out of a total sample of 28 residents. Specifically, Resident #95 alleged a certified nursing aide handled him/her roughly and refused to put the correct sized brief on Resident #95, which was filed as a grievance by the facility, ultimately leading to the same certified nursing aide physically abuse Resident #1.

Inspectors wroteBased on record review and interview, the facility failed to report an allegation of potential abuse for one Resident (#95) out of a total sample of 28 residents. Specifically, Resident #95 reported rough handling of a certified nursing aide to another staff member and the incident was not reported and filed as a grievance.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that an individualized, comprehensive care plan was implemented for one Resident (#106), out of a total sample of 28 residents. Specifically for Resident #106, the facility failed to implement fall mats.

Inspectors wroteBased on record review and interview, the facility failed to provide treatment and care in accordance with professional standards of practice for one Resident (#111), out of a total sample of 28 residents. Specifically, the facility failed to follow physician orders to obtain daily weights for a resident with a diagnosis of congestive heart failure (condition when the heart muscle doesn't pump blood as well as it should causing a potential for fluid buildup/ weight gain), nursing did not obtain daily weights for 3 consecutive days and then Resident #111 was found to have a 5.2-pound weight gain. Findings Include: Review of the facility policy titled Heart Failure - Clinical Protocol, dated as revised November 2018, indicated: 1. The physician will review and make recommendations for relevant aspects of the nursing care plan; [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide care, consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing for one Resident (#473) out of a total sample of 28 residents. Specifically for Resident #473, the facility failed to obtain a physician's order with appropriate settings for an air mattress that was in use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and maintenance of a Peripherally Inserted Central Catheter (PICC: a flexible tube inserted through a vein in one's arm and passed through to the larger veins near the heart, used to deliver medications intravenously [IV] ), consistent with professional standards of practice for one Resident (#106), out of a total sample of 28 residents. Specifically, for Resident #106, the facility failed to change the PICC line dressing as ordered by the physician and the facility failed to obtain weekly measurements for the external length of Resident #106's PICC line to ensure the PICC line had not migrated (moved from the heart to another area, which could have a significant impact on treatment, or cause serious harm).

Inspectors wroteBased on observations and interviews, the facility failed to provide respiratory care service in accordance with professional standards of practice for one Resident (#88) out of a total sample of 28 residents. Specifically, the facility failed to maintain Resident #88 on the Oxygen (O2) level ordered by the physician, failed to change the O2 tubing as ordered by the physician, and failed to implement foam ear protectors on the nasal cannula.

Inspectors wroteBased on record review and interview the facility failed to ensure a care plan was developed for Trauma Informed Care, or Post Traumatic Stress Disorder (PTSD) with resident specific triggers and interventions, for two Residents (#7 and #85) out of a total sample of 28 residents.

Inspectors wroteBased on observation, record review and interview for one Resident (#71) out of a total sample of 28, the facility failed to provide dental care.

Inspectors wroteBased on observation, record review and interview, the facility failed to have one Resident (#93), out of a total sample of 28 residents seen by the oral surgeon after the consulting dentist made the recommendation for tooth extractions and new dentures in May 2024.

Inspectors wroteBased on record review and interview, the facility failed to develop a Quality Assurance Performance Improvement (QAPI) after two allegations of abuse for one certified nursing aide. Specifically, two Residents alleged abuse against the same certified nursing aide, and the facility failed to develop and implement a QAPI plan to prevent quality of care issues and ensure safety of residents.

Inspectors wroteBased on observations, interviews and record review for two Residents (Resident #111 and #2i) out of a total sample of 30 residents, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Specifically, 1a. For Resident #111, the facility failed to implement contact precautions, for a Resident who was diagnosed with Clostridium difficile (C. difficile- an inflammation of the colon). 1b. For Resident #2i, the facility failed to implement contact precautions, for a Resident who was diagnosed with Methicillin-Resistant Staphylococcus Aureus (MRSA- a bacteria that is resistant to several antibiotics).

Inspectors wroteBased on record review and interviews, the facility failed to offer the COVID 19 (Coronavirus disease) vaccine to two out of a sample of six employees. Specifically, the facility failed to offer COVID 19 vaccinations during new hire orientation.

Inspectors wroteBased on record review and interview, the facility failed to accurately complete the Minimum Data Set (MDS) assessment for two Residents (#71 and #47) out of a total sample of 28 residents. Specifically; 1. For resident #71 the facility inaccurately coded dental status on the MDS. 2. For Resident #47 the facility failed to code a feeding tube on the MDS.

Inspectors wroteBased on observation, record review, policy review and interview, the facility failed to provide adequate supervision and ensure an environment free from accidents and hazards, for two Residents (#99 and #92) out of a total sample of 34 Residents. Specifically: 1.) For Resident #99, who was assessed by nursing to be a high risk for falls, the facility failed to ensure he/she received adequate supervision to prevent accidents when he/she experienced 13 falls over a span of 51 days, with two of those falls resulting in injuries which required 6 staples (12/16/23) and 12 sutures (12/29/23). 2.) For Resident #92, the facility failed to implement preventative interventions for accidents in a timely manner resulting in the Resident burning his/her feet on the heater, subsequently causing hospitalization.

Inspectors wroteBased on observation and interview, the 1) facility failed to maintain a homelike environment on two of three resident units and 2) failed to ensure the appropriate water temperatures were maintained in three of three resident units.

Inspectors wroteBased on observations, record review, policy review and interviews, the facility 1) failed to provide incontinence care for three Residents (#49, #51 and #24), 2) failed to obtain physician's orders for the use and care of an indwelling urinary catheter for one Resident (#316) and 3) failed to ensure adequate infection control practices were implemented and the use of a privacy bag was used for one Resident (#75) with an indwelling urinary catheter out of a total sample of 34 residents.

Inspectors wrote3.) For Resident #317 who required a bipap (bilevel positive airway pressure, ventilation machine used to help someone get oxygen at night), the facility failed to obtain physician's orders. Resident #317 was admitted to the facility in January 2024 with diagnoses including interstitial pulmonary disease, pulmonary fibrosis, centrilobular emphysema. Review of the Minimum Data Set (MDS) assessment, dated 1/20/24, indicated Resident #317 had a Brief Interview of Mental Status (BIMS) score of 15 out of a possible 15 which indicated he/she was cognitively intact. Review of the health status note, dated 1/22/24, indicated: -the patient admitted from hospital with history of severe chronic obstructive pulmonary disease (COPD) emphysema with hypoxia, pulmonary hypertension, pleural effusion. He/she is oxygen dependent. He/she uses the BiPAP. [...]

Inspectors wroteBased on staffing level reviews and interviews, the facility failed to ensure that sufficient staffing levels were maintained to safely and adequately meet each resident's personal and cognitive care needs.

Inspectors wroteBased on observations, records reviewed, policy review and interviews, the facility failed to ensure it was free of a medication error rate of five percent or greater when 2 of 4 nurses, on 2 of 3 nursing units made 4 errors in 29 opportunities, totaling a medication error rate of 13.79%. These errors impacted 2 Residents (Resident #32 and #366) out of 6 residents observed.

Inspectors wroteBased on observations, policy review, and interviews the facility failed to 1.) ensure medication carts were locked when unattended on three out of three nursing units and 2.) medications carts were kept clean and orderly in two of four medication carts observed.

Inspectors wrote4. For Resident #94 the facility failed to maintain an accurately documented medical record to reflect the refusal or non-use of Bi-level positive airway pressure (BiPAP), a non-invasive ventilation machine. Resident #94 was admitted to the facility in August of 2023 with diagnoses that include but are not limited to obstructive sleep apnea, chronic pulmonary disease, chronic respiratory failure, emphysema, shortness of breath, anxiety, and depression. Review of Resident #94's most recent Minimum Data Set (MDS), dated [DATE], indicated that the resident had a Brief Interview for Status Mental (BIMS) score of 10 out of a possible 15 indicating that he/she has moderate cognitive impairment. Further review of the MDS indicated that Resident #94 utilized non-invasive mechanical ventilation both on admission and while a resident at the facility. [...]

Inspectors wroteBased on observations, interviews and policy review, the facility failed to ensure resident Protected Health Information (PHI) was secure on 1 of 3 units. Specifically, nurses on the C Unit failed to ensure PHI on the medication administration computers was not visible and accessible on the nursing unit.

Inspectors wroteBased on record reviews and interviews the facility failed to send a copy of a facility initiated 30-day Notice of Intent to Discharge/Transfer to the Office of the State Long-Term Care Ombudsman. Specifically, for one resident (#67) out of a total sample of 34 residents, the Office of the State Long- Term Care Ombudsman was not notified when a facility initiated 30-day Notice of Intent to Discharge/Transfer was issued. Resident #67 was admitted in August of 2023 with diagnoses including, but not limited to, Chronic systolic (congestive) heart failure, muscle wasting and atrophy, morbid obesity, pain, Type 2 Diabetes, and major depressive disorder. Review of the most recent Minimum Data Set (MDS), dated [DATE], indicated Resident #67 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating he/she is cognitively intact. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to implement the plan of care for two Residents (#57 and #99) out of a total sample of 34 residents. Specifically: 1. For Resident #57, the facility failed to provide padded side rails. 2. For Resident #99, the facility failed to implement individualized fall care plan interventions.

Inspectors wroteBased on observations, record review and interview, the facility failed to provide care in accordance with professional standards of practice for one Resident (#76) out of a total sample of 34 Residents. Specifically, for Resident #76, the facility failed to implement the physician's orders for no paper products on meal trays.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide assistance with meals as needed for two Residents (#57, #36) out of a total of 34 sampled residents.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure nursing provided treatment and services consistent with professional standards of practice to promote healing of a pressure ulcer for a one Resident (#316) out of a total sample of 34 Residents. Specifically for Resident #316, who was assessed by nursing to be at risk for skin breakdown and whose hospital paperwork indicated he/she had a stage two pressure ulcer (Partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough), the facility failed to implement interventions to prevent a decline in the pressure ulcer. When on 1/13/24 during the evening shift, nursing observed a dressing on Resident #316's tail bone dated 1/9/24. [...]

Inspectors wroteBased on observations, record review, policy review and interviews, the facility failed to address a significant weight loss for 1 Resident (#97) out of a total sample of 34 residents.

Inspectors wroteBased on interview, policy review, and record review, the facility failed to provide care and maintenance of a peripherally inserted central catheter (PICC), consistent with professional standards of practice for one Resident (#318), out of a total sample of 34 residents. Specifically, for Resident #318 the facility failed to obtain PICC line measurements upon admission and weekly as ordered.

Inspectors wroteBased on records reviewed, policy review and interviews, the facility failed to act upon recommendations made by the Consultant Pharmacist during monthly Medication Regimen Reviews (MRR) for three Residents (#99, #318, #67), out of a total sample of 34 residents. Specifically, the facility staff failed to ensure: 1.) For Resident #99, that the Consultant Pharmacist recommendations were reviewed by facility staff. 2.) For Resident #318, that the Consultant Pharmacist recommendations were reviewed by facility staff. 3.) For Resident #67, that the Consultant Pharmacist recommendations were reviewed by facility staff.

Inspectors wroteBased on record review and interview, the facility failed to ensure that one Resident's (#316) medication regimen was free from unnecessary drugs out of a total sample of 34 Residents. Specifically, for Resident #316 the facility failed ensure he/she was free from an excessive dose (duplicate drug therapy) of medication when Resident #316 had two orders for latanoprost ophthalmic solution (medication used to treat certain types of glaucoma and other causes of high pressure inside the eye).

Inspectors wroteBased on observations, record review, policy review and interviews, the facility failed to provide a diet that met one Resident's (#111) preferences for both likes and dislikes and texture of diet out of a total sample of 34 residents.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure that trash, garbage, and refuse were disposed of properly in the dumpster.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure infection control practices were implemented to prevent the spread of infection, including Covid-19 on one unit out of three resident units. Specifically, staff failed to put on all required Personal Protection Equipment (PPE) and failed to perform hand hygiene when donning PPE prior to entering a resident room, identified by a sign as requiring isolation precautions.

Inspectors wroteBased on record review, policy review and interviews the facility failed to implement their antibiotic stewardship program for antibiotic use for one Resident #99 out of a total sample of 34 Residents. Specifically for Resident #99 the facility failed to implement a duration of treatment for cephalexin (an antibiotic).

Inspectors wroteBased on records reviewed and interviews, for two of four sampled residents, (Resident #1 and Resident #3) the Facility failed to ensure they were treated in a dignified and respectful manner, when on 08/25/23 during the 11:00 P.M. to 7:00 A.M. shift, 1) Certified Nurse Aide (CNA) #1 yelled at Resident #1 due to the frequency of his/her need for assistance to use the commode, and 2) CNA #1 degraded Resident #3 after he/she had a bowel movement in an incontinent brief. Both of the interactions with CNA #1 and Resident #1 and Resident #3, were witnessed by their roommates.