Aspen Place Health Campus

In the surveyor’s words

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

• Actual harm, isolatedF690Apr 28, 2023

  Based on observation, record review, and interview, the facility failed to appropriately secure a resident's catheter, resulting in an injury of a split and wound to the resident's penis (Resident 46), follow the physician's orders related to catheterization (Resident 46), and the proper positioning of an indwelling urinary catheter drainage bag for a resident that developed a UTI (Resident 28) for 2 of 18 residents reviewed. Findings include: 1. During an observation of Resident 46 on 04/26/23 at 2:53 P.M., the ADON (Assistant Director of Nursing) alerted the resident that she was going to observe and cleanse his penis. The resident agreed. The resident's pants and brief were removed. The resident had just had a suprapubic catheter placed. […]

• Actual harm, isolatedF689Mar 1, 2023

  Based on interview, observation, and record review, the facility failed to follow the Emergency Preparation Plan or use a Hoyer lift to transfer a resident, who required the extensive assistance of two staff and a Hoyer lift for transfers, resulting in a fracture for 1 of 3 residents reviewed for accidents. (Resident B) Findings include: The clinical record for Resident B was reviewed on 2/28/23 at 2:45 p.m. A Quarterly MDS (Minimum Data Set) assessment, dated 12/10/22, indicated the resident was severely cognitively impaired. She required extensive assistance of two staff for mobility, transfer, and ADLs (Activities of Daily Living). The diagnoses included, but were not limited to, dementia, heart disease, weakness, and morbid obesity. […]

• Actual harm, isolatedF689Feb 22, 2022

  Based on record review and interview, the facility failed to position a resident in bed appropriately that resulted in a fracture for 1 of 3 residents reviewed for falls. (Resident B) Findings include: The clinical record for Resident B was reviewed on 02/22/22 at 11:00 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 10/08/21, indicated the resident was moderately cognitively impaired. Diagnoses included, but were not limited to, [CONDITION(S)], [CONDITION(S)], hypertension, non-Alzheimer dementia, depression, anxiety, and muscle weakness. The resident had impairments to one side of the upper extremity and both sides of the lower extremities. She required extensive physical assistance of 2 or more staff members with bed mobility. […]

• Actual harm, isolatedF689Oct 19, 2021

  Based on interview and record review, the facility failed to maintain a safe environment, free from accident hazards, and provide adequate supervision, resulting in a major injury for 1 of 3 residents reviewed for accidents. (Resident B) Findings include: During the clinical record review for Resident B on 10/18/21 at 10:24 a.m., the record indicated her diagnoses included but was not limited to, severely cognitively impaired, repeated falls, Alzheimer's, dementia, and cognitive communication deficit. The Annual MDS (Minimum Data Set) dated 9/24/21 indicated Moderate difficulty hearing, unclear speech, understood and understands, vision not assessed. Two person extensive assistance for mobility, transfer, and ADLs. Always incontinent of bladder and bowel. […]

• No harm, potential for more than minimal, patternF880May 13, 2025

  Based on record review, interview, and observation, the facility failed to follow infection control guidelines related to infection tracking and trending, and Enhanced Barrier Precautions (EBP) related to infection control. (Residents 10 and 40) Findings include: 1. During a review of the Infection Control Tracking and Trending documentation on 05/13/25 at 10:08 A.M., The facility lacked documented tracking of antibiotic use for February and March 2025. During an interview on 05/13/25 at 3:35 P.M., the Infection Preventionist indicated she came to this facility in April and infections and antibiotic usage was not tracked in February and March. […]