Aspen Transitional Rehabilitation

In the surveyor’s words

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

• Actual harm, isolatedF600Dec 18, 2025

  Based on staff interview, record review, and review of the State Long Term Care Reporting System, it was determined the facility failed to ensure residents were free from abuse, neglect, and misappropriation of resident property and exploitation. This was true for 1 of 3 residents (Resident #50) reviewed for abuse and neglect. The facility failed to protect Resident #50 when she experienced neglect from CNA #1 during transfer from a chair to standing resulting in a fall with injury requiring hospitalization and surgery. […]

• No harm, potential for more than minimal, widespreadF727Dec 18, 2025

  Based on record review and staff interview, the facility failed to ensure the presence of a registered professional nurse for at least 8 consecutive hours per day, as required. This failure had the potential to affect all residents in the facility who may require a higher level of nursing assessment or intervention. Findings include: Review of the facility's nursing schedule dated 11/23/25 through 12/13/25 documented the facility did not provide 8 consecutive hours of registered professional nursing coverage on the following dates: 11/23/25 - No consecutive hours 11/29/25 - No consecutive hours 11/30/25 - No consecutive hours 12/6/25 - No consecutive hours 12/7/25 - No registered nurse hours 12/13/25 - No consecutive hours On 12/18/25 at 12:12 PM, the DON stated she was unaware that the… […]

• No harm, potential for more than minimal, widespreadF585Jul 27, 2023

  Based on observation, document review, and staff interview, it was determined the facility failed to ensure posted contact information of independent entities with whom grievances may be filed, such as, the State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system was accurate. This failure had the potential for residents and/or their representatives to be unaware of who to voice their care concerns/complaints to. Findings include: The facility lobby was observed on 7/25/23, beginning at 9:07 AM. During the observation, a posted form titled KNOW YOUR RIGHTS was reviewed. […]

• No harm, potential for more than minimal, widespreadF726Jul 27, 2023

  Based on observation, policy review, nursing manual review, competency review, CDC infection control guidelines review, medical record review, and staff interview, it was determined the facility failed to ensure nursing staff had competencies and skill sets to assure resident safety. This was true for 1 of 1 resident (Resident #281) whose PICC line dressing change was observed and whose record was reviewed. This had the potential for increased risk of infection and mechanical failure for all facility residents with PICC lines. Findings include: The CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011 state, Summary of Recommendations .Education, Training, and Staffing .1. […]

• No harm, potential for more than minimal, patternF812Sep 12, 2024

  Based on observation and staff interview, it was determined the facility failed to ensure the kitchen equipment and environment was maintained, clean, and food was stored in a safe and sanitary manner. These deficiencies had the potential to affect the 28 residents who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: The facility's Food Storage policy, updated on 1/9/24, documented: - Date marking will be visible on all high-risk food to indicate the date by which a ready-to-eat, TCS (Time/Temperature for Safety Food) food should be consumed, sold, or discarded. […]