A list of the most recent deficiencies for Aspen Health and Rehab. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-06-05 | 2024-03-13 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-06-05 | 2024-03-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-06-05 | 2024-03-13 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-06-05 | 2024-03-13 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-08-29 | 2023-09-22 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-06-05 | 2023-07-18 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-06-05 | 2023-07-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-05 | 2023-07-18 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-06-07 | 2023-07-07 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-06-07 | 2023-07-07 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-07 | 2023-07-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-07 | 2023-07-07 | N |
| Post nurse staffing information every day. | Health | 2023-06-07 | 2023-07-07 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-06-07 | 2023-07-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-07 | 2023-07-07 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2023-06-05 | 2023-07-07 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-06-05 | 2023-07-07 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-06-05 | 2023-07-07 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-06-05 | 2023-07-07 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2023-06-05 | 2023-07-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-06-05 | 2023-07-07 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-06-05 | 2023-07-07 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-06-05 | 2023-07-07 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-06-05 | 2023-07-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-06-05 | 2023-07-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-06-05 | 2023-07-07 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-06-05 | 2023-06-29 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2023-03-07 | 2023-03-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-12 | 2022-11-04 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-20 | 2022-11-04 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-09-20 | 2022-11-04 | Y |
| Help the resident with transportation to and from laboratory services outside of the facility. | Health | 2022-09-20 | 2022-11-04 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-09-20 | 2022-11-04 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2022-08-31 | 2022-11-04 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-31 | 2022-11-04 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-08-31 | 2022-11-04 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-08-31 | 2022-11-04 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-08-31 | 2022-11-04 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2022-08-31 | 2022-11-04 | Y |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2022-08-31 | 2022-11-04 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-08-31 | 2022-11-04 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-08-31 | 2022-11-04 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-07-20 | 2022-11-04 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-20 | 2022-11-04 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-20 | 2022-11-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-20 | 2022-11-04 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-07-20 | 2022-11-04 | Y |
| Post nurse staffing information every day. | Health | 2022-07-20 | 2022-11-04 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-07-20 | 2022-11-04 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-07-20 | 2022-11-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-20 | 2022-11-04 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-07-20 | 2022-11-04 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-06-02 | 2022-11-04 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2022-06-02 | 2022-11-04 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-06-02 | 2022-11-04 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-06-02 | 2022-11-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-02 | 2022-11-04 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-02 | 2022-11-04 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-06-02 | 2022-11-04 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-06-02 | 2022-11-04 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-06-02 | 2022-11-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-02 | 2022-11-04 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2022-06-02 | 2022-11-04 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-06-01 | 2022-07-30 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-06-01 | 2022-07-30 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2022-06-01 | 2022-07-30 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-06-01 | 2022-07-30 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-06-01 | 2022-07-30 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-06-01 | 2022-07-30 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-06-01 | 2022-07-30 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-06-01 | 2022-07-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-06-01 | 2022-07-30 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-03-21 | 2022-03-30 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-03-21 | 2022-03-30 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2021-10-14 | 2022-02-14 | Y |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2021-04-12 | 2021-05-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-04-12 | 2021-05-20 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-04-12 | 2021-05-20 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-04-12 | 2021-05-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-04-12 | 2021-05-20 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2021-04-12 | 2021-05-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-04-12 | 2021-05-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-04-12 | 2021-05-20 | N |
