Aspen Transitional Rehabilitation

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 required 8 hours of registered professional nursing must be consecutive. She also confirmed the facility did not have a registered professional nurse on duty on 12/7/25.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, it was determined the facility failed to ensure each resident had a person-centered comprehensive care plan developed and implemented to meet his or her preferences, goals, and address the resident's medical, physical, mental and psychosocial needs. This was true for 1 of 2 residents (Resident #50) reviewed for care plans. This deficient practice placed residents at risk for harm when their care plan was not followed. Findings include:Resident #50 was admitted to the facility on [DATE] with multiple diagnoses including congestive heart failure (CHF), bilateral lower leg lymphedema, and diabetes.Resident #50's care plan created on 3/28/25, documented an alteration in mobility/ safety and staff were directed to transfer her using a Hoyer mechanical lift or a 2-person assist. An Abuse Investigation Report completed by the facility documented, on 4/14/25 at 1:10 PM, Resident #50 had a fall with injury in her room while being assisted by CNA #1 from her chair…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure nurses followed provider orders in accordance with professional standards of practice. This was true for 3 of 12 residents (#4, #27, and #38) reviewed for professional standards of care. This failure created the potential for uncontrolled pain, sedation and adverse health outcomes. Findings include:1.Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including osteoporosis with pathological fracture and a history of falls. Review of Resident #4's MAR dated 12/1/25 through 12/17/25 documented the following provider order:Oxycodone 2.5 mg by mouth three times a day for pain level 6-10, as needed. The MAR documented the following oxycodone 2.5 mg administrations outside the ordered pain range: 12/3/25 - pain level 5 (outside ordered range) 12/4/25 - pain level 5 (outside ordered range) 12/7/25 - pain level 4 (outside ordered range) 12/10/25 - pain level 5 (outside ordered range) 12/11/25 - pain level 3 (outside…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, review of the CMS SOM-Appendix PP, and staff interview, it was determined the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys. This was true for 1 of 2 medication carts observed and 1 of 1 medication storage rooms. This deficient practice had the potential for harm to a resident if they were to obtain medications which were left unattended and unsecured by staff. Findings include:CMS SOM-Appendix PP, revised on 7/24/25 and accessed on 12/19/25, documents, in accordance with State and Federal laws, the facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.1) On 12/17/25 at 7:25 AM, the medication cart located in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, CDC recommendation review, and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained during medication preparation and administration. This failure had the potential to impact all residents in the facility by placing them at risk for cross contamination and transmission of infection. Findings include:The Centers for Disease Control and Prevention (CDC) web page titled, Clinical Safety: Hand Hygiene for Healthcare Workers, updated 2/27/24, documented hand hygiene should be performed:Immediately before touching a patient.Before performing an aseptic task such as placing an indwelling device or handling invasive medical devices.Before moving from work on a soiled body site to a clean body site on the same patient.After touching a patient or patient's surroundings.After contact with blood, body fluids, or contaminated surfaces.Immediately after glove removal.The following was observed for hand hygiene and Personal Protective equipment (PPE):On 12/17/25 at 8:08 AM, LPN #1 was observed preparing a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. - Foods will be stored and handled to maintain the integrity of the packaging until ready for use. - All food should be covered, labeled, and dated. - All freezer units will be always kept clean and in good working condition. The FDA (Food Drug Administration) Food Code Section 3-501.17 Ready-to-Eat, TCS food, Date Marking, states marking the date or day the original container is opened in a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interview, and review of grievances, it was determined the facility failed to file a grievance which included the date the grievance was received, steps taken to investigate the grievance, and corrective action taken to resolve the grievance. This was true for 1 of 12 residents (Resident #135) reviewed for grievances and had the potential to impact residents in the facility who may want to file a grievance. This failure created the potential for Resident #135 to experience psychological harm if her grievances were not heard or acted upon. The findings include: The facility Grievance policy and procedure, updated on 9/28/22, documented that patients or representatives can voice a grievance without discrimination or reprisal from the facility. Prompt investigations and resolutions will be made for all grievances patients may have. Patients and families may file an oral or written grievance by completing the Compliment and Concern form or by a staff member. These forms should be given to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, it was determined the facility failed to ensure residents were free from medication errors. This was true for 2 of 5 residents (#134 and #136) whose medication administration were observed. This failure created the potential for harm to residents who received insulin to experience low or high blood sugars when they received an incorrect amount of insulin. Findings include: The American Diabetes Association website, accessed on 9/16/24, stated Priming insulin pens is recommended to remove air from needles to ensure full dose administration. The Insulin Lispro Kwikpen website accessed on 9/16/24, documented to prime insulin pen before each injection. Priming the insulin pen means removing air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. 1. Resident #134 was admitted to the facility on [DATE] with multiple diagnoses including diabetes. A physician's order documented, Resident #134 was to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, observation and staff interview, it was determined the facility failed to ensure infection control measures were consistently implemented. This was true for 2 of 2 residents (#83 and #85) observed during dressing change and resident's cares when staff failed to don a gown and perform hand hygiene during dressing change and resident cares. These deficient practices placed residents at risk of infection from cross contamination. Findings include: The facility's Hand Hygiene policy and procedure, effective 11/3/23, documented handwashing should be performed before applying and removing gloves and after personal use of the toilet. 1. Resident #85 was admitted to the facility on [DATE] with multiple diagnoses including dementia. On 9/10/24 at 10:19 AM, CNA #2 assisted Resident #85 to the bathroom. After using the toilet, CNA #2 asked Resident #85 to stand up, Resident #85 was observed to hold on the hand rail and on the sink as she was standing up and being wiped by CNA #2. CNA #2 then…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. The form included the following inaccurate information: - The form included the address of the State Agency as, 3232 Elder Street, however, the correct address is, 450 W State Street. - The form included the telephone number of the Area Ombudsman as, 1-844-689-7562, however, the correct telephone number is, 1-877-471-2777. - The form included the telephone number of Adult Protection as, 1-844-689-7562, however, the correct telephone number is, 1-877-471-2777. The facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. Educate healthcare personnel regarding the indications for intravascular catheter use, proper procedures for the .maintenance of intravascular catheters, and appropriate infection control measures to prevent intravascular catheter-related infections .2. Periodically assess knowledge of and adherence to guidelines…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, record review, and staff interview, it was determined the facility failed to ensure that residents' advance directives were obtained and this information was documented in their record. This was true for 2 of 12 residents (#128, and #177) whose advance directives were reviewed. This deficient practice created the potential for harm or adverse outcome if the resident's wishes were not followed or documented regarding their advance care planning. Findings include: As defined in the State Operations Manual (SOM), Appendix PP, an advance directive is a written instruction, such as a living will or durable power of attorney for health care, relating to the provision of health care when the individual is incapacitated. An Idaho Physician Orders for Scope of Treatment (POST) is a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and staff interview, it was determined the facility failed to ensure baseline care plans were individualized for 3 of 12 residents (#131, #179, and #188) whose baseline care plans were reviewed. This failure created the potential for resident specific needs to go unrecognized due to lack of information for caregivers. Findings include: Facility policy titled Baseline Care Plans, version A1012, stated the Interim Care Plan is developed during the admission process to direct patient care prior to the development of the Comprehensive Care Plan. The Interim Care Plan is developed from a nursing assessment of the patient's needs, strengths, and weaknesses. The Interim Care Plan is written to include care to be given, goals to be accomplished, and actions necessary to attain the goals. This policy was not followed. 1. Resident #131 was admitted to the facility on [DATE] with multiple diagnoses including depression and metabolic encephalopathy (a chemical imbalance that effects…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, record review, and staff interview it was determined the facility failed to provide a comprehensive, person centered care plan. This was true for 1 of 12 Residents (Resident #6) whose comprehensive care plan was reviewed. This failure created the potential for the resident to receive inappropriate care. Findings include: The facility's policy Comprehensive Care Plan, version A1021, stated the facility will develop a comprehensive person-centered care plan. It stated an individualized care plan should be developed with the input from the patient and/or representative. The policy stated there should be individual-specific interventions and parameters for monitoring progress. This policy was not followed. Resident #6 was admitted to the facility on [DATE] with multiple diagnoses including anxiety and depression. Resident #6's MAR, dated July 2023, documented orders for the following: - Buspirone 7.5 mg (an antianxiety medication),. - Duloxetine 60 mg (an antidepressant medication). Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.