Aspen Meadows Health and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, patternF686Nov 11, 2021

  On 11/10/21 at 5:40 p.m., the facility administrative and corporate personnel were notified that an Immediate Jeopardy existed in the area of F686 - The Prevention of Pressure Ulcers. Severity and Scope identified for the Immediate Jeopardy was identified to be at the level of K, and upon removal of immediacy, lowered to H. Based on observation, interview, and record review, the facility failed to identify, assess, monitor, and treat a Stage two ulcer that progressed to a Stage four ulcer for 1 (#1) resident; failed to prevent a pressure ulcer to the right heel for 1 (#2); and failed to prevent new and worseing pressure ulcers for 1 (#3) of 8 residents reviewed for pressure ulcers. […]

• Immediate jeopardy, isolatedF689Mar 31, 2022

  Based on observation, interview, and record review, the non-smoking facility, failed to thoroughly assess, monitor, supervise, and implement constructive interventions for a resident who was a non-compliant and unsafe smoker, for 1 (#36), and the resident had a history of smoking in the facility, on facility grounds, eloped while smoking or attempting to smoke, had a second degree facial burn from smoking in his room with his oxygen on in May 2021, refused to allow the facility to assist and secure his smoking materials (lighter, cigarettes, and matches). The facility neither had a safe designated smoking area, nor enforced the policy for smoking. […]

• Actual harm, isolatedF600Mar 26, 2026

  Based on interview and record review, the facility failed to identify, correct, and protect a resident who voiced neglect of care concerns, including when the neglect resulted in a lack of care by a staff member (NF7), and this failure contributed to psychosocial harm, for 1 (#47); and when grievances were brought forth, staff did not identify neglect included in the grievances, to neglect continued to occur. The system failure for the prevention of neglect of care contributed to the resident's ongoing anxiety, feelings of being unsafe, decline in mobility, lack of ADL care related to bowel and bladder, and ongoing skin concerns with the resident's ears, heels, and coccyx; out of 19 sampled residents. […]

• Actual harm, isolatedF686Mar 26, 2026

  Based on observation, interview, and record review, the facility failed to ensure the system for pressure ulcer prevention was meeting the residents needs, and the processes used by staff for pressure ulcers did not effectively identify, assess, treat, monitor, or prevent pressure ulcers, which affected 4 (#s 47, 63, 78, and 82) of 28 sampled and supplemental residents. This failure placed the residents at risk for experiencing ongoing skin concerns or negative outcomes related to pressure ulcer development and treatment, stemming from staff not using protective measures to prevent pressure ulcers, not identifying pressure ulcers that developed (or are developing), not assessing or documenting pressure ulcers accurately, not implementing interventions to prevent pressure ulcers, and not… […]

• Actual harm, isolatedF760Mar 26, 2026

  Based in interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 (#4) of 3 sampled residents with insulin orders. The medication error of omission resulted in a deterioration of condition and an unplanned hospitalization for resident #4. Findings include:Review of resident #4's hospitalization, dated between 1/29/26 and 3/23/26 showed the following:- 1/29/26 - 2/20/26, hospitalized ,- 2/20/26 - 2/23/26, in facility, and- 2/23/26 - 2/26/26 hospitalized .Review of resident #4's insulin orders showed the following:- 1/23/26 - 1/29/26, Lantus insulin 10 units every evening, at bedtime,- 2/20/26 - 2/23/26, no order for Lantus insulin,- 2/26/26 - 3/10/26, Lantus insulin 10 units every morning.Review of resident #4's SNF admission… […]