Inspection Reports for
Aspen Point Health and Rehabilitation

The facility failed to maintain a safe, clean, and homelike environment due to leaking windows, unsealed sliding doors, and damaged walls. Infection control practices were inadequate, including failure to change gloves between tasks, improper hand hygiene, and unsafe handling of soiled linens and trash.

The facility was found deficient in reasonable accommodations for residents' needs, privacy and confidentiality of records, baseline care planning, professional standards of care, infection control, nutritional needs, and immunization policies. Multiple residents were affected by these deficiencies, and corrective actions were planned.

The facility was found deficient in multiple areas including failure to ensure call lights were within reach for residents, failure to maintain resident dignity and privacy during care, failure to develop baseline care plans within 48 hours of admission, failure to follow physician orders for treatments and vaccinations, failure to provide adequate assistance with activities of daily living, and failure to prevent unintended weight loss in a resident.

The facility failed to meet several fire safety requirements including enclosure of vertical openings, hazardous area separation, fire alarm system installation and location, smoke detection, sprinkler system maintenance, corridor door integrity, smoke barrier construction, and electrical equipment testing. These deficiencies had the potential to affect occupants in multiple smoke compartments.

The complaint investigation found substantiated reports of staff using foul and degrading language towards residents, which made residents feel bad, worthless, angry, and upset. The facility census was 53 at the time of the investigation.

The facility failed to ensure residents were treated with respect and dignity, as multiple residents reported staff using foul language and speaking in a rough, degrading manner. The Director of Nursing and Administrator acknowledged the issue as a dignity concern after being informed of the residents' reports.

The facility was found deficient in maintaining a safe and homelike environment, timely reporting and investigating abuse and injuries, safe resident transfers, sufficient staffing, food safety, infection prevention and control, equipment maintenance, and staff training. Immediate jeopardy was identified related to staffing and safe transfers but was removed after corrective actions.

The complaint investigation was substantiated with findings of abuse, neglect, and inadequate care. The facility failed to properly investigate allegations and protect residents from harm. Multiple residents had unexplained injuries and the facility did not ensure adequate supervision or timely reporting.

The facility was found to have multiple deficiencies including failure to safeguard resident funds, inadequate environment maintenance, insufficient staff to meet resident needs, and failure to properly investigate and prevent abuse and neglect. Several residents had unexplained injuries and the facility failed to ensure adequate supervision and care.

The facility was found deficient in multiple areas including emergency preparedness policies, staff training, fire drills, sprinkler system maintenance, and fire door integrity. The facility census was 54 and total capacity was 180. Several deficiencies were cited with potential impact on residents and staff safety.

The facility had multiple deficiencies including failure to provide residents access to funds on weekends, inadequate maintenance of the physical environment, failure to report and investigate abuse and injuries, insufficient PASRR screenings, inadequate assistance with activities of daily living such as showers, unsafe resident transfers with malfunctioning mechanical lifts, insufficient staffing levels, serving food at unsafe temperatures, poor kitchen sanitation, uncovered dumpsters, frequent changes in administration, failure to implement infection control precautions, lack of water management program, incomplete staff training and education, and failure to maintain equipment in safe working order.

The facility failed to provide necessary care and assistance with bathing, grooming, personal hygiene, and nail care to three residents unable to perform these activities independently. Additionally, one resident was not checked for incontinence for a prolonged period, resulting in being wet and soiled.

The facility failed to ensure one resident received necessary care and services as ordered by the physician, specifically regarding medication administration and monitoring of laboratory tests. The resident with liver disease became lethargic and dehydrated due to missed doses of lactulose and lack of timely lab work and physician notification.

The complaint investigation found substantiated failure to administer medication and obtain laboratory tests as ordered, leading to resident harm including hospitalization.

The facility failed to administer lactulose as ordered and did not follow up on laboratory tests, resulting in a resident becoming lethargic, dehydrated, and hospitalized with elevated ammonia and critical electrolyte levels. Staff failed to notify the physician timely and did not adequately monitor or document the resident's condition.

The facility was found deficient in multiple areas including housekeeping services, medication administration, assistance with activities of daily living, pressure ulcer care, nursing staff sufficiency, and the role of the director of nursing. All deficiencies were noted with minimal harm or potential for actual harm to residents.

The facility failed to ensure proper Tuberculosis (TB) testing for new employees and did not request or verify criminal background checks for several employees. These deficiencies posed risks related to communicable disease exposure and employment of potentially disqualified staff.

The facility was found to be in noncompliance with several Life Safety Code requirements including means of egress, fire alarm system testing and maintenance, electrical systems maintenance, and emergency power system maintenance. Deficiencies had the potential to affect all 60 residents.

The facility was found deficient in multiple areas including failure to prevent verbal abuse between residents, medication administration errors and delays, inadequate assistance with activities of daily living including bathing and incontinence care, failure to prevent and properly treat pressure ulcers, significant unaddressed weight loss in residents, insufficient nursing staffing including licensed nurse coverage, and failure to provide bedtime snacks as required.

The complaint investigation substantiated that Resident #1 and Resident #2 did not receive their prescribed pain medications as ordered. Resident #1 experienced uncontrolled pain and self-discharged early. Resident #2 missed multiple doses due to lack of prescription refill and medication availability, resulting in increased pain and reduced activity.

The facility failed to obtain and administer prescribed pain medications timely for two residents, resulting in increased pain and distress. Medication orders were not properly communicated or filled, and medications were documented as administered when they were not given.

The facility failed to notify a resident's physician and responsible party of a significant change in condition resulting in an emergency room visit. The facility also failed to maintain a safe, clean environment and follow professional standards of care for residents, including oxygen therapy and documentation. Multiple deficiencies were cited related to furniture, room cleanliness, medication administration, and respiratory care.

The complaint investigation focused on failure to notify physicians and family of resident condition changes, failure to maintain safe and clean environment, failure to provide appropriate respiratory care, and failure to follow professional standards of practice for feeding and oxygen therapy. Substantiation is implied by the detailed findings and interviews.

The facility failed to notify the physician and family of a resident's significant change in condition resulting in hospitalization. The facility also failed to maintain resident rooms and equipment in good repair, failed to follow professional standards for oxygen therapy and documentation, and failed to properly implement respiratory care including labeling and changing oxygen tubing as ordered.

The facility failed to ensure three residents were free from misappropriation of property, specifically involving narcotic medications. An investigation revealed that a Licensed Practical Nurse (LPN A) misappropriated Resident #1's narcotic pain medication, leading to the nurse's termination and corrective actions including staff education and policy review.

The complaint investigation substantiated that LPN A diverted narcotic medications from residents #1, #3, and #5. The investigation included interviews, record reviews, and policy assessments. LPN A resigned when asked to take a drug test and was terminated. The facility corrected the deficiency by 11/21/23.

The facility failed to ensure three residents were free from misappropriation of property when LPN A diverted residents' narcotic medications. The investigation confirmed narcotic diversion, leading to LPN A's resignation and termination. The facility reviewed and reinforced policies on abuse, neglect, and controlled substance administration.

The complaint investigation substantiated failures in resident rights protection, dignity and respect, safe care and supervision, infection control practices, and staffing adequacy. Immediate jeopardy related to infection control was identified on 11/07/23 and removed on 11/09/23 after corrective actions.

The facility failed to protect residents' rights to voice concerns without fear of retaliation, failed to provide adequate supervision and safe care resulting in falls and injuries, failed to properly disinfect glucometers and perform perineal care, and failed to maintain adequate staffing levels. Immediate jeopardy was identified related to infection control practices but was removed after corrective actions.

The facility had multiple deficiencies including failure to promptly address resident council grievances, medication administration errors, inadequate wound care, lack of supervision leading to a resident choking incident resulting in death, failure to ensure adequate meal portions and snacks, incomplete medication regimen reviews, lack of a qualified infection preventionist, and failure to implement an effective antibiotic stewardship program. The facility also failed to maintain a functional Quality Assurance and Performance Improvement program with proper documentation and participation.

The facility was found deficient in multiple areas including failure to ensure residents' rights and dignity, improper use of chemical restraints, failure to report and investigate abuse allegations timely and thoroughly, failure to provide proper transfer/discharge notices, failure to administer medications as ordered, inadequate accident prevention and supervision, failure to prevent weight loss, inadequate pain management, insufficient staffing, and improper infection control practices.

The complaint investigation was substantiated. The facility was found to have failed in maintaining a safe environment and protecting residents from verbal abuse. The verbal abuse incident involving Licensed Practical Nurse D was confirmed by interviews and observations.

The facility failed to maintain a clean and comfortable environment, with observations of spills, trash, ants, and mold. The facility also failed to protect a resident from verbal abuse by a Licensed Practical Nurse, and failed to ensure proper medication administration and reporting of alleged violations.

The facility failed to maintain a clean and homelike environment, protect residents from verbal abuse, provide adequate assistance with activities of daily living, ensure proper medication administration including psychotropic and insulin medications, and maintain proper licensing and insurance for the facility van used for resident transportation. Additionally, the facility failed to timely refund a resident's funds. Immediate jeopardy was identified related to medication errors and transportation issues but was removed after corrective actions.

The facility failed to provide hand soap and disposable towels in resident bathrooms, did not follow physician orders for medication administration due to an electronic system failure, and served food at unsafe temperatures. These deficiencies were noted as uncorrected from previous inspections.

The complaint was substantiated. The resident's family member witnessed via camera the CNA lifting the resident off the floor without a gait belt and roughly transferring the resident to bed, causing pain. The facility failed to investigate the allegation properly and did not protect the resident from potential harm.

The facility failed to follow its policy to maintain documentation and complete a thorough investigation of the alleged resident abuse. Staff failed to use a gait belt when lifting the resident off the floor and did not implement interventions for recurring falls. The former administrator did not initiate an investigation despite being informed of the incident.

The facility was found deficient in maintaining a safe, clean, and homelike environment, including issues with resident room ceilings, walls, flooring, doors, and resident equipment. Deficiencies were also noted in professional standards for care, medication administration, behavioral management, and environmental cleanliness.

The complaint investigation found no deficiencies cited initially, but subsequent review revealed failure to notify the resident's personal representative and failure to timely report an allegation of abuse. The allegation was substantiated as the facility did not notify family or report the incident within required timeframes.

The facility failed to notify the resident's personal representative of a change in condition and failed to report an allegation of abuse timely to required entities. The facility did not notify the family of the allegation or injury of unknown origin within the required timeframe.

The complaint investigation was substantiated. The violation was determined to be at an imminent danger Class I level based on observation, interview, and record review. The facility had implemented corrective action to remove the Immediate Jeopardy at the time of exit, with a final revisit planned to verify substantial compliance.

The facility failed to appropriately transfer Resident #1 using a gait belt, resulting in two falls causing serious injuries including fractures. The facility did not document or investigate the first fall properly and failed to notify the physician timely. The facility's fall prevention and gait belt use policies were reviewed and found deficient in practice.

The inspection identified multiple deficiencies related to resident funds management, housekeeping and maintenance issues, abuse/neglect policies, admission screening, care planning, medication administration, infection control, and dietary services. Several residents' care plans and medical records lacked required documentation and timely updates.

The facility was found to have multiple deficiencies related to fire safety, including failure to maintain fire barriers, inadequate exit signage, unsecured hazardous areas, and improperly maintained fire extinguishers. The facility capacity was 180 with a census of 95 at the time of inspection.

The facility was found to be in compliance with 42 CFR483.73 related to emergency preparedness but failed to maintain an infection control program as evidenced by inadequate PPE use, hand hygiene, and cleaning practices during the COVID-19 pandemic.

The complaint investigation was substantiated. The facility failed to provide reasonable accommodations for a hearing impaired resident and failed to report alleged misappropriation of resident property timely. Additional deficiencies were found related to medication administration, staffing, restorative nursing services, and treatment of residents with mental health diagnoses.

The facility was found to have multiple deficiencies including failure to provide reasonable accommodations for a hearing impaired resident, failure to report alleged misappropriation of a resident's property timely, inadequate medication administration and documentation, insufficient nursing staff, and failure to provide restorative nursing services as ordered. The facility also failed to ensure appropriate treatment for residents with mental health diagnoses and did not adequately address aggressive behaviors.

The complaint was substantiated based on interviews, record reviews, and statements showing the LPN verbally abused a resident with repeated use of profanity and disruptive behavior.

The facility failed to prevent verbal abuse of one resident by an LPN who used inappropriate language and disruptive behavior. The administrator acknowledged the verbal abuse and expects residents to be free from such abuse.

The facility was found to have multiple deficiencies related to resident rights, quality of care, safety, and medication management. Specific issues included failure to protect resident dignity, inadequate care planning, improper use of restraints, and medication administration errors.

The facility was found deficient in multiple areas including discharge from exits, illumination of means of egress, emergency lighting, cooking facilities maintenance, fire alarm system testing, sprinkler system installation and maintenance, smoke barrier construction, fire drills, smoking regulations, and electrical systems maintenance. Deficiencies had the potential to affect residents and occupants in various smoke compartments.

The complaint investigation was substantiated. The facility failed to report abuse allegations timely and failed to prevent further abuse during the investigation involving Resident #3.

The facility failed to report allegations of abuse to the state agency within two hours of the incident and failed to prevent further potential abuse during the investigation. Staff did not report or investigate the abuse allegations timely, and the facility did not follow its abuse prevention policies.

The complaint investigation was substantiated based on interviews, record reviews, and observations confirming abuse incidents involving Resident #1 and Resident #2.

The facility failed to prevent sexual abuse of Resident #2 by Resident #1, including incidents where Resident #1 touched Resident #2's breasts and placed hands down Resident #2's pants. The facility did not adequately update care plans or intervene appropriately to prevent further abuse.

The facility failed to meet professional standards of care by not following physician's orders for four residents, including inadequate documentation and medication administration issues. Deficiencies were cited related to comprehensive care plans and nursing care per resident conditions.

The facility failed to provide scheduled showers for several residents dependent on staff for bathing and failed to provide necessary treatment and services to prevent and treat pressure ulcers for one resident. Multiple residents lacked documentation of showers during the review period, and a new pressure ulcer was identified without timely treatment.

The facility failed to provide adequate personal hygiene care for dependent residents, including insufficient showering and bathing assistance. Additionally, the resident call system was not functioning properly, resulting in delayed staff response to resident calls for assistance.

The facility was found deficient in multiple areas including housekeeping and maintenance, grievance procedures, notice requirements before transfer or discharge, baseline care plans, infection control, medication management, food safety, and immunization policies. The plan outlines corrective actions to address these deficiencies.

The facility failed to develop and maintain adequate emergency preparedness plans addressing subsistence needs, evacuation procedures, training, and emergency power systems. Additionally, the facility did not meet life safety code requirements related to means of egress, illumination, fire barriers, sprinkler systems, electrical systems, and smoking regulations.

The facility was found deficient in protecting residents' rights to private communication and maintaining a safe, clean, and homelike environment. Issues included unauthorized opening of resident mail and water intrusion causing unsafe conditions in multiple resident rooms.

The facility failed to develop and implement comprehensive, person-centered care plans for residents, including measurable objectives and timely updates. Deficiencies were noted in care planning related to pressure ulcers and pain management for multiple residents.