Aspen Place Health Campus

Inspectors wrote2. The clinical record for Resident 10 was reviewed on 05/08/25 at 1:33 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 03/09/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, Chronic Obstructive Pulmonary Disease (COPD), hypertension, heart failure, dementia. The resident had an unhealed pressure ulcer on her right buttocks. An open-ended physician's order, with a start date of 12/13/24, indicated staff were to use Enhanced Barrier Precautions (EBP), wearing a gown and gloves at minimum during high contact care activities. During an observation, on 05/12/25 2:09 P.M., the resident's door had a sign on it that indicated staff were to STOP and that the resident was in ENHANCED BARRIER PRECAUTIONS. Everyone must wear gloves and a gown for High-Contact Resident Care Activities, including wound care. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the staff had the required six hours of dementia training within six months of hire and three hours annually for 3 of 10 employee records reviewed. (CNA 2, CNA 3, and CNA 5)

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse in a timely manner for 1 of 15 residents reviewed for reporting of alleged violations. (Resident 20)

Inspectors wroteBased on record review and interview, the facility failed to follow a physician's order related to blood pressure monitoring for 1 of 15 residents reviewed for quality of care. (Resident 26)

Inspectors wroteBased on interview and record review, the facility failed to ensure residents with a urinary tract infection received antibiotic treatment in a timely manner for 2 of 15 residents reviewed for laboratory services. (Resident 26 and 31)

Inspectors wrote2. The clinical record for Resident 26 was reviewed on 05/08/25 at 10:35 A.M. A Quarterly Minimum Data Set assessment, dated 04/18/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, acute respiratory failure with hypoxia, hypertension, non-Alzheimer dementia, malnutrition, anxiety, depression, and psychotic disorder. The resident's clinical record lacked documented meals for the following dates and times for a resident with a diagnosis of malnutrition: [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure medications were available for 1 of 15 residents reviewed for pharmacy services. (Resident 26)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered appropriately to prevent significant medication errors for 1 of 3 residents reviewed for significant medication errors. (Resident 23)

Inspectors wroteBased on observation and interview, the facility failed to appropriately store medications for 1 of 3 medication carts reviewed (100 Hall Medication Cart).

Inspectors wroteBased on observation, interview, and record review, the facility failed to appropriately store medications for 1 of 2 medication carts reviewed (300 Hall Medication Cart), and for 1 of 2 medication rooms (300 Hall Medication Room) reviewed.

Inspectors wroteBased on observation and interview, the facility failed to store food appropriately for 1 of 2 kitchen observations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess a resident to self-administer medications for 1 of 14 residents reviewed. (Resident 43)

Inspectors wroteBased on record review and interview, the facility failed to provide bathing for 2 of 3 residents reviewed for Activities of Daily Living. (Residents D and E)

Inspectors wroteBasedonobservation interview andrecordreview thefacilityfailedtofollowappropriateinfectioncontrolguidelinesrelatedtoindwelling urinarycathetersforaresidentwhohadahistoryofUTIs(UrinaryTractInfections for1 of3 residentsreviewedforurinarycatheters/ UTIs (Resident34)

Inspectors wroteBased on record review and interview, the facility failed to follow hospital discharge orders and verify admission weights for 1 of 3 residents reviewed for hydration/nutrition. (Resident D)

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow appropriate infection control guidelines related to storage and dating of respiratory supplies for 3 of 4 residents reviewed for respiratory care. (Residents C, D, and E)

Inspectors wrote2. During an observation on 04/24/23 at 1:42 P.M., the resident was sitting in his recliner with the urinary catheter drainage bag hanging on the right side of the chair and resting on the floor. During an observation on 04/26/23 at 4:02 P.M., the resident was sitting in his recliner with the urinary catheter drainage bag hanging on the right side of the chair and resting on the floor. The record for Resident 28 was reviewed on 04/27/233 at 11:06 A.M. An admission MDS, dated [DATE], indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, prostate cancer, heart failure, hypertension, diabetes, and renal insufficiency. The resident had had a UTI in the last 30 days and had an indwelling urinary catheter. [...]

Inspectors wroteBased on record review and interview, the facility failed to notify the physician of a change in a resident's condition for 1 of 18 resident's review. (Resident 15)

Inspectors wroteBased on interview and record review, the facility failed to provide activities of daily living related to routine bathing for 1 of 24 residents reviewed. (Resident 26)

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physician's order related to dressing changes for 1 of 6 residents reviewed for skin conditions (Resident 14)

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physicians' orders for the interventions/treatments of pressure ulcers for 2 of 5 residents reviewed for pressure ulcers. (Residents 16 and 31)

Inspectors wroteBased on record review and interview, the facility failed to implement recommendations from the RD in a timely manner for 1 of 2 residents reviewed for nutrition. (Resident 1)

Inspectors wroteBased on record review and interview, the facility failed to follow Care Plan interventions following a self-harm allegation for 1 of 5 residents reviewed for unnecessary medications. (Resident 3)

Inspectors wroteBased on record review and interview, the facility failed to have medications available for 2 of 18 residents reviewed for pharmacy services. (Residents 16 and 1)

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent a significant medication error related to Coumadin (a blood thinner) for 1 of 18 residents reviewed. (Resident 31)

Inspectors wroteBased on record review and interview, the facility failed to follow a physician's order related to obtaining laboratory test for 1 of 18 residents reviewed. (Resident 15)

Inspectors wroteBased on interview and record review, the facility failed to demonstrate that ongoing corrective actions were in place to address a significant medication error related to Coumadin for 1 of 18 residents reviewed. (Resident 31)

Inspectors wrote2. During an observation on 04/24/23 at 1:17 P.M., CNA (Certified Nurse Aide) 13 placed a graduated cylinder on the end of the resident's bed. She held the urinary catheter drainage bag with an ungloved hand above the graduated cylinder and above the resident's bladder. She removed the drainage tube from the holder on the urinary drainage bag with her gloved left hand, unclamped the tube, and emptied the urine from the urinary drainage bag. She closed the clamp on the tube, placed it back in the holder on the side of the urinary drainage bag, and hung the urinary drainage bag on the side of the bed. She measured the urine, took the graduated cylinder to the bathroom, emptied it in the toilet, and rinsed the graduated cylinder. The clinical record for Resident 38 was reviewed on 04/26/23 at 1:36 P.M. [...]