Deficiencies (last 4 years)
Deficiencies (over 4 years)
6.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
14% better than Idaho average
Idaho average: 7.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Dec 18, 2025
Visit Reason
The inspection was conducted based on a complaint investigation regarding allegations of abuse, neglect, and failure to follow professional standards of care at Aspen Transitional Rehabilitation.
Complaint Details
The complaint investigation found substantiated neglect of Resident #50 during transfer by CNA #1, resulting in a fall and injury requiring surgery. The facility corrected the non-compliance as of 4/16/25 with retraining and audits. Additional complaints included failure to follow medication orders for residents #4, #27, and #38, inadequate RN coverage, medication security lapses, and infection control failures.
Findings
The facility was found to have failed to protect a resident from neglect during transfer resulting in a fall with injury requiring hospitalization and surgery. Additional deficiencies included failure to develop and implement comprehensive care plans, failure to follow provider medication orders, inadequate registered nurse coverage, improper medication storage and handling, and failure to maintain infection prevention and control practices during medication administration. The facility demonstrated correction of neglect-related non-compliance as of 4/16/25.
Deficiencies (6)
Failure to protect resident from abuse and neglect resulting in fall with injury requiring hospitalization and surgery.
Failure to develop and implement a complete care plan meeting resident's needs with measurable timetables and actions.
Failure to ensure nurses followed provider medication orders, resulting in medication administration outside ordered pain levels.
Failure to ensure presence of a registered nurse on duty for at least 8 consecutive hours per day.
Failure to store drugs and biologicals in locked compartments and maintain proper medication security.
Failure to maintain infection prevention and control practices during medication preparation and administration.
Report Facts
Dates of transfer audits: 5/16/25, 6/16/25, 7/16/25
Dates of nursing schedule deficiencies: 11/23/25, 11/29/25, 11/30/25, 12/6/25, 12/7/25, 12/13/25
Medication administration dates outside ordered range: 7
Medication administration dates outside ordered range: 2
Medication administration dates outside ordered range: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Named in neglect finding for transferring Resident #50 alone resulting in fall and injury. | |
| LPN #1 | Licensed Practical Nurse | Named in medication security and infection control deficiencies related to medication cart and preparation. |
| DON | Director of Nursing | Interviewed regarding neglect incident, medication administration, RN coverage, medication security, and infection control. |
Inspection Report
Routine
Deficiencies: 4
Date: Sep 12, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident grievances, medication administration, food safety, and infection control at Aspen Transitional Rehabilitation.
Findings
The facility was found deficient in multiple areas including failure to properly document and address resident grievances, medication administration errors related to insulin pen priming, inadequate food storage and sanitation practices in the kitchen, and inconsistent implementation of infection prevention and control measures such as hand hygiene and gown use during resident care.
Deficiencies (4)
Failure to file a grievance including date received, investigation steps, and corrective action for Resident #135.
Failure to ensure residents were free from medication errors; insulin pens were not primed before administration for Residents #134 and #136.
Failure to maintain kitchen equipment and environment clean and food stored safely; issues included undated food items, ice buildup, and flaking pipe insulation contaminating storage areas.
Failure to consistently implement infection control measures; staff failed to don gowns and perform hand hygiene during dressing changes and resident care for Residents #83 and #85.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 28
Residents affected: 2
Medication administration observed: 5
Insulin doses: 5
Insulin doses: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Reported grievance from Resident #135 and educated CNA #1 |
| LPN #3 | Licensed Practical Nurse | Administered insulin pens without priming for Residents #134 and #136 |
| CNA #1 | Certified Nursing Assistant | Educated regarding inappropriate terms used with residents related to grievance |
| CNA #2 | Certified Nursing Assistant | Failed to assist Resident #85 with hand hygiene after restroom use |
| LPN #2 | Licensed Practical Nurse | Failed to wear gown and perform hand hygiene during dressing change for Resident #83 |
| NSD | Nutritional Services Director | Provided information about kitchen conditions and freezer issues |
| IP | Infection Preventionist | Provided statements on proper gown use and hand hygiene during dressing changes |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Jul 27, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to residents' rights, care planning, grievance policies, and nursing competencies, including advance directives, baseline and comprehensive care plans, grievance contact information, and nursing skills for PICC line care.
Findings
The facility failed to ensure residents' advance directives were obtained and documented, baseline and comprehensive care plans were individualized and person-centered, grievance contact information was accurate, and nursing staff had appropriate competencies for PICC line dressing changes. These deficiencies posed potential risks for resident safety and care quality.
Deficiencies (5)
Failed to ensure residents' advance directives were obtained and documented in their records for 2 of 12 residents (#128 and #177).
Failed to ensure posted contact information of independent entities for grievances was accurate.
Failed to ensure baseline care plans were individualized for 3 of 12 residents (#131, #179, and #188).
Failed to provide a comprehensive, person-centered care plan for 1 of 12 residents (Resident #6).
Failed to ensure nursing staff had competencies and skill sets to safely perform PICC line dressing changes, including lack of documented competency, improper technique, and missing baseline catheter measurements for 1 resident (Resident #281).
Report Facts
Residents reviewed for advance directives: 12
Residents reviewed for baseline care plans: 12
Residents reviewed for comprehensive care plans: 12
Residents affected by PICC line competency deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Observed performing PICC line dressing change with competency and skill deficiencies |
| DON | Director of Nursing | Interviewed regarding advance directives, care plans, and nursing competencies |
| CNM | Certified Nursing Manager | Interviewed regarding infection control and nursing competencies; reviewed PICC line dressing change |
| [NAME] President of Clinical Services | President of Clinical Services | Interviewed regarding PICC line care policies and competencies |
| Regional [NAME] President of Operations | Regional President of Operations | Interviewed regarding nursing competencies and PICC line dressing change policies |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Jul 27, 2023
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements related to resident rights, care planning, grievance policies, and nursing competencies.
Findings
The facility failed to ensure residents' advance directives were obtained and documented, failed to maintain accurate grievance contact information, did not individualize baseline and comprehensive care plans for residents with mental health diagnoses, and nursing staff lacked competencies and skills to safely perform PICC line dressing changes, posing potential risks to resident safety.
Deficiencies (5)
Failed to ensure residents' advance directives were obtained and documented in their records for 2 of 12 residents reviewed.
Failed to ensure posted contact information for grievance entities was accurate.
Failed to ensure baseline care plans were individualized for 3 of 12 residents reviewed.
Failed to provide a comprehensive, person-centered care plan for 1 of 12 residents reviewed.
Failed to ensure nursing staff had competencies and skill sets to safely perform PICC line dressing changes, including lack of documented competency and failure to follow infection control guidelines.
Report Facts
Residents reviewed for advance directives: 12
Residents affected by advance directive deficiency: 2
Residents reviewed for baseline care plans: 12
Residents affected by baseline care plan deficiency: 3
Residents reviewed for comprehensive care plan: 12
Residents affected by comprehensive care plan deficiency: 1
Residents affected by PICC line competency deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in PICC line dressing change competency and skill set deficiency |
| DON | Director of Nursing | Interviewed regarding advance directives and care plan deficiencies |
| CNM | Certified Nursing Manager | Interviewed and observed PICC line dressing change; responsible for infection control and nursing competencies |
| [NAME] President of Clinical Services | President of Clinical Services | Interviewed regarding PICC line competency and supplies |
| Regional [NAME] President of Operations | Regional President of Operations | Interviewed regarding nursing competencies and PICC line dressing change policy |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Sep 6, 2019
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with regulatory requirements for Aspen Transitional Rehabilitation, including review of resident rights, transfer and discharge procedures, baseline care plans, medication management, food safety, and immunization policies.
Findings
The facility was found deficient in multiple areas including failure to document and provide advance directives to residents, failure to provide timely transfer and bed hold notices, incomplete baseline care plans regarding code status, inadequate documentation supporting continued use of PRN psychotropic medications, unsanitary kitchen equipment, and failure to properly track and document pneumococcal vaccinations according to CDC guidelines.
Deficiencies (7)
Failure to ensure residents' records included documentation of Advance Directives or facility policy discussion for 12 of 12 residents reviewed.
Failure to provide timely written transfer notices to residents and representatives, including Resident #25.
Failure to provide written notice of bed hold policy to residents or representatives upon hospital transfer, including Resident #25.
Failure to document residents' code status on baseline care plans for 2 of 12 residents reviewed (#80 and #129).
Failure to ensure clinical rationale documented for continued use of PRN lorazepam beyond 14 days for 2 of 5 residents reviewed (#9 and #15).
Failure to maintain kitchen equipment in a sanitary manner, including build-up of blackened food debris on gas burners and oven.
Failure to implement an immunization program that tracked pneumococcal vaccine types and ensure immunizations were offered or provided as indicated for 5 of 5 residents reviewed.
Report Facts
Residents reviewed for Advance Directives: 12
Residents reviewed for baseline care plans: 12
Residents reviewed for PRN lorazepam use: 5
Residents reviewed for pneumococcal immunizations: 5
Gas top grill burners with blackened food debris: 4
Ovens with build-up of grease and food debris: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Reported residents' living wills were kept in charts but admissions staff did not always obtain copies | |
| LPN #2 | Reported offering Advance Directive information but not documenting it | |
| Director of Nursing (DON) | Provided multiple statements regarding Advance Directives, transfer notices, bed hold policy, baseline care plans, medication management, immunization tracking, and facility deficiencies | |
| Certified Dietary Manager | Acknowledged kitchen equipment was not cleaned as expected | |
| Administrator | Confirmed facility was not providing bed hold notices on hospital transfers | |
| LPN #3 (MDS Nurse) | Reported being unaware of responsibility to track residents' immunizations until informed by DON |
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