Aspen Health and Rehab

In the surveyor’s words

From the most serious findings on record at Aspen Health and Rehab, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Apr 2, 2025

  On 04/01/25 at 9:18 a.m., an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure residents were free from abuse and neglect. A nurse's statement, dated 03/27/25 at 11:15 p.m., showed Resident #1 reported to RN #1, CNA #1 on the evening shift was mean and hurt them. Resident #1 reported CNA #1 threw them on the bed hard enough to make the bed move and hurt them every time CNA #1 was their aide. Resident #1 reported CNA #1 had been hurting them for a while and they were afraid to report it because they were afraid CNA #1 would get meaner. RN #1 documented Resident #1 broke down into tears crying and asked to keep CNA #1 out of their room. On 03/31/25 at 11:39 a.m., Resident #1 stated the incident on 03/27/25 made them feel abused in a way. […]

• No harm, potential for more than minimal, patternF584Jun 6, 2025

  Based on observation and interview, the facility failed to maintain comfortable sound levels in halls, by resident rooms, and resident common areas of the facility. The facility alphabetical room roster showed there were 100 residents. On 06/04/25 at 4:30 p.m., several children were observed in the second floor billiard room, playing with the billiard balls on the billiard table by slamming the billiard balls against one another. The children's voices were loud. On 06/04/25 at 6:00 p.m., two children were observed entering the elevator. The children appeared to be under the age of 10 and each wore the walkie-talkie style headset the staff wore for inter-facility communication. On 06/04/25 at 6:15 p.m., a group of children stood in the first floor hallway, near an open office door. […]

• No harm, potential for more than minimal, patternF684Mar 3, 2025

  Based on record review and interview, the facility failed to ensure medication orders from the physician were implemented for 2 (#2 and #4) and failed to ensure daily weights were obtained as ordered by the physician for 1 (#4) of 3 sampled residents who were reviewed for quality of care. The ADON identified 113 residents who received medications and 20 residents who were ordered daily weights. Findings: 1. Resident #2 had diagnoses which included low back pain and chronic pain. A physician order, dated 02/23/24, showed Resident #2 had been ordered cyclobenzaprine (a muscle relaxer) 10 mg every 12 hours as needed. The progress note by the physician, dated 02/20/25 at 2:01 p.m., read in part, Discontinue cyclobenzaprine. […]

• No harm, potential for more than minimal, patternF770Mar 3, 2025

  Based on record review and interview, the facility failed to ensure labs were completed as ordered by the physician for 2 (#2 and #6) of 3 sampled residents whose labs were reviewed. The ADON identified 113 residents who resided in the facility. Findings: 1. Resident #2 had diagnoses which included chronic obstructive pulmonary disease. The progress note by the physician, dated 02/20/25 at 2:01 p.m., read in part, Please obtain readmit labs. Review of the clinical record did not show the readmission labs had been completed. On 02/27/25 at 4:19 p.m., the DON stated the charge nurses were responsible to ensure physician orders from the progress notes were implemented. […]

• No harm, potential for more than minimal, patternF583Jul 3, 2024

  Based on observation and interview, the facility failed to secure protected health information for six (Resident #206, #310, #315, #316, and Resident #318) of six residents whose protected health information was observed in a bin secured to the wall outside of a social service office. The administrator identified 113 residents in the facility. Findings: On 06/30/24, during the initial tour, the protected health information for six (Resident #206, #310, #315, #316, and Resident #318) of six residents was observed hand written on six sheets of paper observed in a a wall bin just outside of an office for social services. […]