Aspen Ridge West Transitional Rehab

In the surveyor’s words

From the most serious findings on record at Aspen Ridge West Transitional Rehab, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF880Jan 14, 2026

  Based on observation, interview, and record review, the facility did not maintain an infection and prevention control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, for 3 out of 26 sampled residents, Enhanced Barrier Precautions (EBP) were not implemented for residents with wounds and indwelling medical devices. Additionally, clean linens were found to be on the floor in the laundry room. Resident identifiers:15, 17, and 55.Findings included: 1. On 1/12/26 at 8:12 AM, an initial tour of the facility was conducted. It should be noted that there was no EBP signage for residents 3, 15, 17.a. […]

• No harm, potential for more than minimal, patternF880Jun 30, 2021

  Based on observation, interview, and record review it was determined the facility did not maintain an infection prevention and control program (IPCP) designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, when entering and exiting isolation rooms staff were observed not donning and doffing Personal Protective Equipment (PPE) per the IPCP, a resident's catheter bag was observed on several occasions to be left on the resident's floor without a barrier, a visitor was observed within an isolation room without wearing PPE, and cross contamination was observed during dining service. Resident identifiers: 83, 88, and 131. Findings include: 1. […]

• No harm, potential for more than minimal, isolatedF554Jan 14, 2026

  Based on observation, interview, and record review, the facility did not ensure the right to self-administer medications if the interdisciplinary team had determined that this practice was clinically appropriate. Specifically, for 1 out of 26 sampled residents, it was found that the resident did not have a nursing assessment or a physician's order in place to be able to self-administer medications. Resident identifier: 2Findings included: Resident 2 was admitted to the facility on [DATE] with diagnoses which included displaced transverse fracture of shaft of right fibula, displaced fracture of lateral malleolus of left fibula, age-related osteoarthritis, and diverticulitis of large intestine.On 1/12/26 at 10:18 AM, an interview was conducted with resident 2. […]

• No harm, potential for more than minimal, isolatedF755Jan 14, 2026

  Based on interview and record review, the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, for 1 out of 26 sampled residents, the resident was not provided with multiple medications due to them being out of stock and unavailable from the pharmacy. Resident identifier: 3.Findings included: Resident 3 was admitted to the facility on [DATE] with diagnoses which included fracture of first lumbar vertebra, nondisplaced zone II fracture of sacrum, and chronic kidney disease.Review of resident 3's medical record was completed on 1/12/26 through 1/14/26.On 12/12/25, a physician's order was started for eszopiclone to be given at bedtime.Resident 3's December 2025 Medication Administration Record (MAR) revealed that the eszopiclone was not… […]

• No harm, potential for more than minimal, isolatedF883Jan 14, 2026

  Based on interview and record review, the facility did not ensure that residents were offered the pneumococcal immunization and that the medical records included documentation that the resident either received the immunization or did not due to medical contraindications or refusal. Specifically, for 2 out of 5 sampled residents, there was no documentation of declination of the pneumococcal immunization. Resident identifiers: 15 and 55.Findings included:1. Resident 15's medical record was reviewed 1/12/26 through 1/14/26. A form labeled PNA [pneumonia], FLU [Influenza] COVID [Coronavirus Disease 2019], RSV [respiratory syncytial virus] Immunizations, Medication Consent was located in resident 15's medical record. The form was signed by resident 15 and dated 12/30/25. […]