Aspen Hill Rehabiliation & Healthcare Center

In the surveyor’s words

From the most serious findings on record at Aspen Hill Rehabiliation & Healthcare Center, in the surveyor’s own words.

• Actual harm, patternF689Jan 25, 2024

  Based on observation, record review, policy review and interview, the facility failed to provide adequate supervision and ensure an environment free from accidents and hazards, for two Residents (#99 and #92) out of a total sample of 34 Residents. Specifically: 1.) For Resident #99, who was assessed by nursing to be a high risk for falls, the facility failed to ensure he/she received adequate supervision to prevent accidents when he/she experienced 13 falls over a span of 51 days, with two of those falls resulting in injuries which required 6 staples (12/16/23) and 12 sutures (12/29/23). […]

• Actual harm, isolatedF656Mar 11, 2025

  Based on records reviewed and interviews, for one of three sampled residents (Resident #3), whose comprehensive plan of care and Care Kardex (a summary of the resident's care needs, utilized by Certified Nurse Aides) indicated he/she required staff assistance with ambulation, the Facility failed to ensure staff consistently implemented and followed interventions related to ambulation, per his/her plan of care. On 02/11/25, Certified Nurse Aide (CNA) #2 saw Resident #3 ambulating by him/herself, and although she thought he/she required staff supervision with ambulation, CNA #2 did not provide him/her with supervision or assistance (per the plan of care) with ambulation. […]

• Actual harm, isolatedF689Mar 11, 2025

  Based on records reviewed and interviews, for one of three sampled residents (Resident #3), who was assessed by nursing as being at risk for falls, the Facility failed to ensure he/she was provided with the necessary level of staff assistance to prevent an incident resulting in an injury. On 02/11/25, Certified Nurse Aide #2, who was familiar with and had provided care to Resident #3, observed him/her ambulating alone, but did not provide or get another staff member to assist or supervise him/her. […]

• Actual harm, isolatedF600Jan 16, 2025

  Based on record review and interview, the facility failed to keep one Resident (#1) free from abuse out of a total sample of 28 residents. Specifically, an allegation of abuse was made by Resident #95 and filed as a grievance, subsequently allowing the accused certified nursing aide to continue working, which led to the physical abuse of Resident #1. Findings include: Review of the facility policy titled Abuse, Neglect, Exploitation and Missapropriation Prevention Program, undated, indicated the following: - Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misapporopriation of resident property. - Investigate and report any allegations within timeframes required by federal requirements. […]

• Actual harm, isolatedF610Jan 16, 2025

  Based on record review and interview, the facility failed to 1a. investigate an allegation of potential abuse for one Resident (#95), which 1b. failed to keep Resident (#1) free from abuse, out of a total sample of 28 residents. Specifically, Resident #95 reported to staff having been rough handled by a certified nursing aide. The report was not thoroughly investigated, which allowed the accused certified nursing aide to continue working, and eventually abuse Resident #1. Findings include: Review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, revised September 2022, indicates the following: -All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident… […]