Aspen Meadows Health and Rehabilitation Center

Inspectors wroteBased on interview and record review, the facility failed to identify, correct, and protect a resident who voiced neglect of care concerns, including when the neglect resulted in a lack of care by a staff member (NF7), and this failure contributed to psychosocial harm, for 1 (#47); and when grievances were brought forth, staff did not identify neglect included in the grievances, to neglect continued to occur. The system failure for the prevention of neglect of care contributed to the resident's ongoing anxiety, feelings of being unsafe, decline in mobility, lack of ADL care related to bowel and bladder, and ongoing skin concerns with the resident's ears, heels, and coccyx; out of 19 sampled residents. This failure also put other residents at risk of neglect due to the system failures and neglect not being addressed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the system for pressure ulcer prevention was meeting the residents needs, and the processes used by staff for pressure ulcers did not effectively identify, assess, treat, monitor, or prevent pressure ulcers, which affected 4 (#s 47, 63, 78, and 82) of 28 sampled and supplemental residents. This failure placed the residents at risk for experiencing ongoing skin concerns or negative outcomes related to pressure ulcer development and treatment, stemming from staff not using protective measures to prevent pressure ulcers, not identifying pressure ulcers that developed (or are developing), not assessing or documenting pressure ulcers accurately, not implementing interventions to prevent pressure ulcers, and not updating resident care plans for pressure ulcer prevention.

Inspectors wroteBased in interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 (#4) of 3 sampled residents with insulin orders. The medication error of omission resulted in a deterioration of condition and an unplanned hospitalization for resident #4.

Inspectors wroteBased on interview and record review, the facility failed to fully investigate allegations of abuse and neglect for 3 (#s 26, 47, and 77) of 28 sampled and supplemental residents. The deficient practice failed to ensure the facility identified all residents who may have been abused or neglected, in an attempt to prevent ongoing or future abuse or neglect.

Inspectors wroteBased on interview and record review, the facility failed to complete a baseline care plan that provided instructions needed to provide resident centered care for 3 (#s 11, 78 and 82) of 28 sampled and supplemental residents. The failure to have a baseline care plan placed the residents at risk of not being provided care to meet their basic needs.

Inspectors wroteBased on interview and record review, the facility failed to provide education and information to the residents or responsible party on the risks and benefits of psychotropic medication, so they were able to make an informed decision, and the facility did not have documentation to show the resident/responsible party consented to the use of the medications, for 2 (#s 2 and 83) of 19 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's right to have visitors of their choice for 1 (#53) of 28 sampled and supplemental residents. Specifically, the facility failed to allow resident #53's friend to visit her in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide written notice of charges not covered when the resident was no longer receiving Medicare skilled services for 1 (#89) of 3 residents sampled for coverage notifications.

Inspectors wroteBased on interview and record review, the facility failed to ensure a grievance was completed for an abuse and neglect allegation for 1 (#47); and failed to thoroughly investigate and document the findings for 1 (#53) of 28 sampled and supplemental residents. This deficient practice resulted in resident #47 reported feeling afraid and more anxious when NF7 would care for resident #47. Resident #47 also felt neglected in his care at the facility and feared retaliation for speaking up about NF7's care at the facility. The deficient practice affecting resident #53 increased the risk of discomfort from not repositioning the resident for comfort.

Inspectors wroteBased on interview and record review, the facility failed to timely report an abuse and neglect allegation to the State Survey Agency for 1 (#47) of 19 sampled residents.

Inspectors wroteBased on interviews and record reviews the facility failed to provide written documentation to the resident and/or the resident's representative upon transfer. The resident or representative was not provided with documentation showing the reason for transfer and the opportunity to enact a bed hold for 1 (#78); and the facility failed to send a copy of the notice of hospital transfer to the local facility Ombudsman for 2 (#s 47 and 78) of 28 sampled and supplemental residents. This deficient practice affected the resident's ability to ensure the transfer was appropriate and did not allow the resident or representative to request the facility to hold their bed. The deficient practice prevented the Ombudsman from tracking transfers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident assessment was completed accurately for 2 (#s 2 and 24) of 19 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan for 1 (#63) of 19 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately document the ADL services offered for 2 (#s 47 and 51), failed to offer a washcloth in the morning for 2 (#s 47 and 51), failed to offer mouthwash for 1 (#47), and failed to provide ADL assistance for a dependent resident for 1 (#22) of 19 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure an antibiotic medication order had an adequate indication for 1 (#19) of 19 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure pneumonia and Covid-19 (coronavirus-19) vaccines were offered per CDC recommendations for 3 (#s 23, 51, and 55) of 28 sampled and supplemental residents.

Inspectors wroteBased on interview and record review, the facility failed to schedule sufficient staff to ensure call lights were answered timely for 3 (#s 1, 2, and 3) of 7 sampled residents, and staff were using mechanical lifts with the appropriate number of staff for 1 (#5) of 7 sampled residents. This deficient practice had the potential to negatively impact all residents who use a call light by causing incontinent episodes and increases the risk of injury for all residents who need a mechanical lift for transfers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who had medications left at bedside was assessed, and a physician's order was obtained for the safe self-administration of medications, for 1 (#5) of 7 sampled residents.

Inspectors wroteBased on interview and record review, facility staff failed to provide pertinent medical information to the receiving facility at the time of transfer for 2 (#s 35 and 43) of 17 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a resident-centered baseline care plan for 1 (#115) of 17 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a comprehensive, resident-centered care plan which identified residents' physical and psychosocial needs to reach their highest practicable level of well-being for 1 (#9) of 17 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to update a care plan to reflect a new surgical wound, and wound management, for 1 (#14) of 17 sampled residents. The failure placed the resident at risk for improper wound care, wound deterioration, or infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely ADL services to a dependent resident for 1 (#9) of 17 sampled residents. This failure placed the resident at increased risk for falls, injury, psychological distress, and pain.

Inspectors wroteBased on interview and record review, the facility failed to ensure a pharmacist's recommendation for gradual dose reductions were addressed for two psychotropic medications ordered by a provider for 1 (#40) of 5 sampled residents for medication regimen review.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff practiced appropriate use of personal protective equipment (PPE), during care of a resident on enhanced barrier precautions (EBP) for 1 (#9) of 17 sampled residents. The failure increased the risk of MDRO infections within the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance with ADL's for dependent residents, for 4 (#s 8, 23, 39 and 65) of 20 sampled residents, and the residents were found to be unkempt, there was noticable body odor, and one voiced concerns of feeling neglected.

Inspectors wroteBased on interview and record review, the facility failed to ensure all controlled substance medications were accurately administered, accounted for, and documented, for 2 (#s 13 and 35) of 20 sampled residents.

Inspectors wroteBased on observation, interview, and record review, facility staff failed to identify care concerns for a resident who was restricted to right lower extremity non-weight bearing status, and failed to develop and implement a baseline care plan within 48 hours of admission, to address resident care needs, for 1 (#4) of 20 sampled residents.

Inspectors wroteBased on interview and record review, licensed nurses failed to uphold and provide competent nursing services by failing to administer medication by following the professional standards of medication administration, for 2 (#s 6 and 13) out of 20 sampled residents.

Inspectors wroteBased on interview and record review, licensed nurses failed to uphold and provide competent nursing services by failing to administer medication by following the professional standards of medication administration, for 2 (#s 6 and 13) out of 20 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide wound care as ordered by the provider; and failed to implement and document physician ordered interventions intended to mitigate worsening of a pressure ulcer, for 1 (#14) of 3 sampled residents with pressure wounds. These deficient practices contributed to the worsening of a pressure ulcer from nearly healed to a Stage III ulcer on the resident's heel.

Inspectors wroteBased on observation and interview, the facility failed to provide clean resident rooms for 6 (#s 10, 11, 19, 26, 40, and 41), of 28 sampled residents, and failed to provide clean public restrooms, which had the potential to affect all staff and visitors who use the facility's public restrooms.

Inspectors wroteBased on interview and record review, the facility failed to provide a written transfer/discharge notice to a resident or resident representative at the time of transfer from the facility for 3 (#s 9, 23, and 40) of 28 sampled residents.

Inspectors wroteBased on observation and interview, the facility failed to remove expired medications from three medication carts. This failure had the potential to affect all residents who receive medication from the three carts.

Inspectors wroteBased on interview and record review, the facility failed to report a facility reported incident within the required timeframe for 1 (#38) of 28 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to consistently provide and document restorative nursing services for residents with a decline in functional status, for 2 (#s 12 and 49) of 4 sampled residents with restorative service concerns.