Aspen Trace Health & Living Community

In the surveyor’s words

From the most serious findings on record at Aspen Trace Health & Living Community, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF812Jul 14, 2023

  Based on observation, interview, and record review, the facility failed to ensure foods were served in a sanitary and safe manner for 2 of 3 kitchen observations. Staff hair was not covered while in the kitchen food preparation area. (Cook 2, Dietary Manager) Findings include: 1. During a follow-up kitchen observation on 7/5/23 from 11:30 a.m. to 11:50 a.m., the following was observed: a. Cook 2 was observed walking through out the kitchen area where the noon meal was being prepared and was observed near the steam table and near the food carts where the noon meal was being held. […]

• No harm, potential for more than minimal, isolatedF558Apr 28, 2025

  Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of needs for 1 of 22 residents reviewed for resident call light access. (Resident 12) Finding includes: On 4/22/25 at 9:18 a.m., Resident 12 was observed sitting up in bed. The over-the-bed table was in front of the resident. Resident 12's call light was observed hanging from the headboard behind the resident's left shoulder. The call light was out of sight and out of reach of Resident 12. During an interview at that time, Resident 12 indicated she did not know where her call light was. […]

• No harm, potential for more than minimal, isolatedF761Apr 28, 2025

  Based on observation, interview, and record review, the facility failed to ensure medications were labeled with an open date for 1 of 4 medication carts observed. An insulin pen was not labeled with an open date. (Renaissance 2 Medication Cart) Finding includes: On 4/22/25 at 8:30 a.m., the Renaissance 2 Medication Cart was observed. An opened Insulin Flex Pen 100 units/ml (milliliter) lacked labeling indicating the date the insulin pen was opened or to whom it was prescribed. […]

• No harm, potential for more than minimal, isolatedF656Jul 14, 2023

  Based on observation, interview, and record review, the facility failed to follow the plan of care for 1 of 4 residents reviewed for medication administration. Physician's orders were not followed. (Resident B) Finding includes: During an observation on 7/6/23 at 8:55 a.m., Registered Nurse (RN) 3 was observed preparing Resident B's medications with the DON present. When RN 3 got to the order for the dabigatran etexilate (Pradaxa) medication, RN 3 indicated that the medication was not available and that it had been reordered from the pharmacy. Neither staff member knew the generic name for the medication. […]

• No harm, potential for more than minimal, isolatedF842Dec 30, 2022

  Based on interview and record review, the facility failed to ensure a medical record were complete for 1 of 3 residents reviewed for medical records. (Resident B) Finding includes: During an interview on 12/29/22 at 2:07 p.m., Resident B indicated she was sent to the hospital a few weeks ago but she didn't remember why. The clinical record for Resident B was reviewed on 12/30/22 at 8:31 a.m. The diagnosis included, but was not limited to, anxiety disorder. A Quarterly MDS (Minimum Data Set) assessment, dated 9/22/22, indicated Resident B was cognitively intact. A hospital discharge summary, dated 10/7/22, indicated Resident B was sent to the emergency department and diagnosed with aspiration and pneumonia. […]