Aspen Health and Wellness

In the surveyor’s words

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

• Actual harm, isolatedF692Jan 13, 2025

  The facility identified a census of 62 residents. The sample included three residents reviewed for weight loss. Based on record review and interviews, the facility failed to implement interventions to prevent further weight loss for Resident (R) 1 after she experienced a significant weight loss, and the facility implemented an initial intervention in September 2024. R1 continued to experience significant weight loss and Consultant GG followed R1 but did not recommend further interventions to prevent weight loss and the facility failed to implement further weight loss prevention interventions. This deficient practice resulted in a significant weight loss of 25.6% for R1. […]

• Actual harm, isolatedF600Jul 3, 2024

  The facility identified a census of 83 residents. The sample included three residents. Based on observation, record review, and interview, the facility failed to prevent an incident of resident-to-resident sexual abuse when Resident (R) 1, who had a history of inappropriate sexual behaviors with a recent escalation, exposed his genitals to R2, a cognitively impaired resident unable to consent. This deficient practice resulted in a negative reaction from R2 and placed the residents at risk for impaired psychosocial well-being including fear and embarrassment, and risk for ongoing sexual abuse. […]

• Actual harm, isolatedF689Nov 29, 2023

  The facility identified a census of 79 residents. The sample included three residents with two reviewed for accidents. Based on observation, record review, and interviews, the facility failed to ensure Resident can 1 remained free from accidents when Certified Nurse Aide can (CNA) M propelled R1 down the hallway in her wheelchair, without a foot pedal for her right leg/foot. This caused R1's foot to get stuck under the wheelchair and resulted in a fracture (broken bone) to her right leg. The facility further failed to prevent accidents for R2 when CNA N failed to utilize two people with a Hoyer lift (total body mechanical lift) transfer which resulted in R2 slipping out of the lift sling and landing on the floor. […]

• No harm, potential for more than minimal, widespreadF725Jun 26, 2025

  The facility identified a census of 58 residents. The sample included 14 residents. Based on observation, record review, and interviews, the facility failed to ensure sufficient staffing to ensure adequate resident care and call light response. This placed the facility residents at risk for a decline and inadequate resident care being completed. Findings Included: - A review of the facility's Payroll-Based Journal (PBJ -Staffing Data Report) from 04/01/22 through 03/31/25 indicated the facility triggered for One Star Staffing for Fiscal Year (FY) 2024 Quarter Three 04/01/24-06/30/24), FY 2024 Quarter Four (07/01/24-09/30/24), FY 2025 Quarter One (10/01/24-12/31/24), and FY 2025 Quarter Two (01/01/25-03/31/25). […]

• No harm, potential for more than minimal, widespreadF880Jun 26, 2025

  The facility identified a census of 58 residents. The facility identified fifteen residents on Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record reviews, observations, and interviews, the facility failed to ensure trash was stored and contained properly. The facility further failed to ensure that catheter bags were kept off the floor. The facility further failed to ensure that respiratory equipment, such as a BIPAP (a type of noninvasive ventilation used to assist breathing) mask, a nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) mask, and a nasal cannula, was stored in a sanitary manner. […]