Inspection Reports for Aspen Health and Rehab

The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure grievances were filed without fear of reprisal for a resident.

The facility failed to protect Resident #3's right to voice grievances without fear of reprisal. Evidence included grievance forms, interviews, and video showing staff discouraging complaints and suggesting alternative placement if complaints continued.

The complaint involved Resident #3 reporting that social services staff threatened them with transfer if they continued to complain. The grievance forms and video evidence supported the claim. The complaint was substantiated based on record review, interviews, and video.

The inspection was conducted to assess compliance with regulatory requirements related to resident rights and care, including maintaining a safe, clean, and comfortable environment and adherence to residents' plans of care.

The facility failed to maintain comfortable sound levels due to unsupervised children causing noise and disturbances in resident areas. Additionally, staff failed to follow the plan of care for one resident, resulting in an improper transfer without the use of a mechanical lift, causing the resident knee injury and distress.

The inspection was conducted due to allegations of abuse and neglect reported by residents and staff, triggering an Immediate Jeopardy (IJ) situation related to failure to protect residents from abuse and neglect.

The facility failed to protect residents from physical abuse and neglect by staff, as evidenced by multiple resident reports and staff admissions of abuse and neglect. An Immediate Jeopardy was identified and later lifted after a plan of removal was implemented, including staff inservice and competency exams. The deficient practice remained at a pattern level with potential for more than minimal harm.

The complaint investigation substantiated abuse and neglect allegations involving three residents (#1, #2, and #3). Resident #1 reported physical abuse by CNA #1 and neglect by CNA #2. Resident #2 and #3 reported neglectful and abusive behaviors by staff. The administrator suspended CNA #1 and implemented corrective actions including staff inservice and competency testing.

The inspection was conducted to investigate complaints related to abuse reporting, accuracy of resident assessments, implementation of physician orders, and completion of laboratory tests at Aspen Health and Rehab.

The facility failed to timely report an allegation of abuse to the State Agency within 2 hours, failed to ensure accurate resident assessments, failed to implement physician medication orders and daily weights, and failed to complete physician-ordered laboratory tests for several residents.

The complaint investigation revealed failure to timely report abuse allegations, inaccurate resident assessments, failure to implement physician orders including medication discontinuation and daily weights, and failure to complete ordered laboratory tests.

The inspection was conducted to assess compliance with regulatory requirements related to resident privacy, care interventions, catheter use, medication monitoring, medication storage, and sanitation.

The facility was found deficient in securing protected health information, developing interventions for limited range of motion, assessing the need for indwelling urinary catheters, monitoring side effects of psychotropic medications, documenting medication storage temperatures, locking medication carts, and ensuring garbage containers in the kitchen were covered.

The inspection was conducted due to a complaint investigation regarding the facility's failure to follow physician's orders when administering medication to a resident.

The facility failed to hold administration of Metoprolol for Resident #1 as ordered by the physician when the resident's systolic blood pressure was below 120, resulting in multiple instances where the medication was administered despite low blood pressure readings.

The complaint was substantiated as the Licensed Practical Nurse and Director of Nursing confirmed that Metoprolol should have been held when the resident's systolic blood pressure was below 120.

The inspection was conducted to evaluate compliance with care plan participation requirements and medication administration accuracy in the facility.

The facility failed to ensure that residents or their representatives were invited to and participated in care plan conferences for one resident. Additionally, medication errors were observed in three of thirteen residents during medication administration, resulting in a 12% medication error rate.

The inspection was conducted to assess the facility's compliance with timely transmission of Minimum Data Set (MDS) assessments to the State, focusing on whether assessments were transmitted within the required timeframe.

The facility failed to ensure timely transmittal of MDS assessments for three of four sampled residents reviewed, resulting in late transmissions beyond the required 7-day period. The delay was attributed to technical issues related to facility name changes and initial access problems for MDS transmissions.