Aspen Transitional Rehabilitation

Inspectors wroteBased on staff interview, record review, and review of the State Long Term Care Reporting System, it was determined the facility failed to ensure residents were free from abuse, neglect, and misappropriation of resident property and exploitation. This was true for 1 of 3 residents (Resident #50) reviewed for abuse and neglect. The facility failed to protect Resident #50 when she experienced neglect from CNA #1 during transfer from a chair to standing resulting in a fall with injury requiring hospitalization and surgery.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the presence of a registered professional nurse for at least 8 consecutive hours per day, as required. This failure had the potential to affect all residents in the facility who may require a higher level of nursing assessment or intervention.

Inspectors wroteBased on observation, record review, and staff interview, it was determined the facility failed to ensure each resident had a person-centered comprehensive care plan developed and implemented to meet his or her preferences, goals, and address the resident's medical, physical, mental and psychosocial needs. This was true for 1 of 2 residents (Resident #50) reviewed for care plans. This deficient practice placed residents at risk for harm when their care plan was not followed.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure nurses followed provider orders in accordance with professional standards of practice. This was true for 3 of 12 residents (#4, #27, and #38) reviewed for professional standards of care. This failure created the potential for uncontrolled pain, sedation and adverse health outcomes.

Inspectors wroteBased on observation, review of the CMS SOM-Appendix PP, and staff interview, it was determined the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys. This was true for 1 of 2 medication carts observed and 1 of 1 medication storage rooms. This deficient practice had the potential for harm to a resident if they were to obtain medications which were left unattended and unsecured by staff.

Inspectors wroteBased on observation, CDC recommendation review, and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained during medication preparation and administration. This failure had the potential to impact all residents in the facility by placing them at risk for cross contamination and transmission of infection.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to ensure the kitchen equipment and environment was maintained, clean, and food was stored in a safe and sanitary manner. These deficiencies had the potential to affect the 28 residents who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses.

Inspectors wroteBased on resident and staff interview, and review of grievances, it was determined the facility failed to file a grievance which included the date the grievance was received, steps taken to investigate the grievance, and corrective action taken to resolve the grievance. This was true for 1 of 12 residents (Resident #135) reviewed for grievances and had the potential to impact residents in the facility who may want to file a grievance. This failure created the potential for Resident #135 to experience psychological harm if her grievances were not heard or acted upon.

Inspectors wroteBased on observation, record review and staff interview, it was determined the facility failed to ensure residents were free from medication errors. This was true for 2 of 5 residents (#134 and #136) whose medication administration were observed. This failure created the potential for harm to residents who received insulin to experience low or high blood sugars when they received an incorrect amount of insulin.

Inspectors wroteBased on policy review, observation and staff interview, it was determined the facility failed to ensure infection control measures were consistently implemented. This was true for 2 of 2 residents (#83 and #85) observed during dressing change and resident's cares when staff failed to don a gown and perform hand hygiene during dressing change and resident cares. These deficient practices placed residents at risk of infection from cross contamination.

Inspectors wroteBased on observation, document review, and staff interview, it was determined the facility failed to ensure posted contact information of independent entities with whom grievances may be filed, such as, the State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system was accurate. This failure had the potential for residents and/or their representatives to be unaware of who to voice their care concerns/complaints to.

Inspectors wroteBased on observation, policy review, nursing manual review, competency review, CDC infection control guidelines review, medical record review, and staff interview, it was determined the facility failed to ensure nursing staff had competencies and skill sets to assure resident safety. This was true for 1 of 1 resident (Resident #281) whose PICC line dressing change was observed and whose record was reviewed. This had the potential for increased risk of infection and mechanical failure for all facility residents with PICC lines.

Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to ensure that residents' advance directives were obtained and this information was documented in their record. This was true for 2 of 12 residents (#128, and #177) whose advance directives were reviewed. This deficient practice created the potential for harm or adverse outcome if the resident's wishes were not followed or documented regarding their advance care planning.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure baseline care plans were individualized for 3 of 12 residents (#131, #179, and #188) whose baseline care plans were reviewed. This failure created the potential for resident specific needs to go unrecognized due to lack of information for caregivers.

Inspectors wroteBased on policy review, record review, and staff interview it was determined the facility failed to provide a comprehensive, person centered care plan. This was true for 1 of 12 Residents (Resident #6) whose comprehensive care plan was reviewed. This failure created the potential for the resident to receive inappropriate care.