Pennsylvania Department of Health
ASPEN NURSING AND REHAB CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

ASPEN NURSING AND REHAB CENTER
Inspection Results For:

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ASPEN NURSING AND REHAB CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and Civil Rights Compliance survey, completed on August 13, 2026, it was determined that Aspen Nursing and Rehab Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.60(c)(1)-(7) REQUIREMENT Menus Meet Resident Nds/Prep in Adv/Followed:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.60(c) Menus and nutritional adequacy.
Menus must-

§483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.;

§483.60(c)(2) Be prepared in advance;

§483.60(c)(3) Be followed;

§483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups;

§483.60(c)(5) Be updated periodically;

§483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and

§483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices.

Observations:

Based on review of the facility's written menus, as well as observations and staff interviews, it was determined that the facility failed to follow their planned menu.

Findings include:

Interviews with residents during a Resident Council meeting on August 11, 2026, at 1:00 p.m. revealed that menus are not always followed and the resident's often do not get what is on the posted menu.

The facility's written and posted weekly menu for the lunch meal on August 12, 2026, revealed that the residents were to receive seasoned broccoli, blushing pears and a dinner roll.

Observations during the lunch meal on August 12, 2026, at 11:45 a.m. revealed that the residents were served mixed vegetables, mandarin oranges and they were not served a dinner roll.

Interview with Dietary Aide 1 during the lunch meal on August 12, 2026, at 12:07 p.m. revealed that he did not look for the broccoli, did not have enough pears, felt that the residents had dinner rolls the day before and did not need one for the lunch meal and did not notify anyone of the changes.

Interview with the Nursing Home Administrator on August 12, 2026, at 12:35 p.m. confirmed that the menu should be followed and if changes are made the residents should be notified.

28 Pa. Code 211.6(a) Dietary services.

28 Pa. Code 201.29(j) Resident rights.

Plan of Correction - To be completed: 09/14/2026

Education was provided to the dietary staff regarding following posted menus.
Any required changes to the menus will be verified with the Registered Dietician to ensure proper nutritional value.
Menus requiring changes will be posted for resident attention in the main dining room.
Nursing Home Administrator will monitor posted menus for accuracy and notification of any changes as well as follow up with Resident Council for resident satisfaction at monthly meetings. Results will be provided to the Quality Assurance Committee.

483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in §483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

§483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9).

Observations: Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the physician was notified that a resident's medication was unavailable for one of 29 residents reviewed (Resident 11). Findings include: An admission Minimum Data Set (MDS) assessment for Resident 11, dated May 15, 2026, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, had an indwelling urinary catheter (a tube inserted and held in the bladder to drain urine), and had diagnoses that included Benign Prostatic Hyperplasia (BPH- condition in which the prostate gland [a walnut-sized gland in the male reproductive system that sits directly below the bladder] grows larger than normal). Physician's orders for Resident 11 dated August 6, 2026, included for the resident to receive 30 milliliters (ml) of Renacidin Irrigation Solution (medical irrigation solution used inside the lower urinary tract to dissolves specific types of bladder stones and prevent mineral buildup or clogs in indwelling urinary catheters) to irrigate his catheter every shift for sediment for seven days, clamping for 30-60 minutes. Review of the Treatment Administration Record (TAR) for Resident 11 dated August 2026, revealed that from August 6 at 9:58 p.m. through August 9 at 10:00 p.m., for a total of 11 administrations, the medication/irrigation was not administered because the medication was not available from the pharmacy. There was no documented evidence that the physician was notified that the medication was unavailable and therefore not administered as ordered. Interview with the Director of Nursing on August 13, 2026, at 10:02 a.m. confirmed that the physician was never notified that the above-mentioned medication for Resident 11 was not available from the pharmacy and therefore not administered on the dates identified and the physician should have been notified. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Plan of Correction - To be completed: 09/14/2026

On August 13, 2026 a review of resident records indicated that Resident 11 did not receive Renacidin irrigation solution as ordered. The Renacidin was not delivered and unavailable from the pharmacy. Physician was then made aware and new orders were received for an alternative treatment.
Education by the Director of Nursing/designee will be provided to licensed nursing staff to report medications or treatments which are not available. Registered Nurse is to notify physician of medication/treatments that are not available/missed. Documentation of physician notification and response is to be documented in the resident's chart
The Director of Nursing or designee will complete a 7-day look back on orders received, checking that treatments and medications were given as ordered. If medication or treatment is not available or missed, documentation will be reviewed for physician notification and alternative orders.
The Director of Nursing or designee will complete daily audits for 1 week on all new medication/treatment orders, 2 x weekly audits for 2 weeks, then weekly for 2 weeks on residents receiving new medication or treatment orders and if physician was notified if not given.
All audits will be reviewed by Interdisciplinary Team during monthly Quality Assurance meetings.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:

§483.21(b) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Observations:

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for two of 29 residents reviewed (Residents 2 and 11).

Findings include:

The facility's policy regarding comprehensive person-centered care plans, dated July 28, 2026, indicated that assessments of residents are ongoing and care plans are revised as information about the residents' condition changed.

An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated June 16, 2026, revealed that the resident was cognitively intact, required assistance for daily care needs, and had diagnoses that included generalized anxiety and cancer.
Review of an advanced directive form (legal document that explains your choices for medical care if you become too sick or hurt to speak for yourself) for Resident 2 dated December 30, 2025, indicated that the resident wanted a code status of DNR (Do Not Resuscitate-informs health care providers not to perform CPR [cardiopulmonary resuscitation ] if a person's heart stops beating) and no hospitalizations.

Physician's orders for Resident 2, dated December 31, 2025, included that the resident's code status was to be a DNR.

The care plan for Resident 2 dated September 15, 2025, indicated that the resident had advanced directives, her code status was to be reviewed quarterly, and CPR would be performed as ordered.

An admission Minimum Data Set (MDS) assessment for Resident 11, dated May 15, 2026, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, had an indwelling urinary catheter, and had diagnoses that included hyponatremia (Condition that happens when the level of sodium in the blood is lower than the typical range. Sodium helps regulate the amount of water that's in and around cells).

The care Plan for Resident 11 dated May 11, 2026, indicated that the resident's fluid intake was restricted to 1200 milliliters (ml) of fluid a day.

Nurse's note dated May 26, 2026, at 1:21 p.m. indicated that the resident was seen by the provider and a new order was provided to discontinue the resident's fluid restriction.

Interview with the Director of Nursing on August 13, 2026, at 10:02 a.m. confirmed that Resident 2's care plan should have been revised to indicate that the resident was a DNR, and Resident's 11's care plan should have been revised to indicate he was not on a fluid restriction.

28 Pa. Code 211.12(d)(5) Nursing Services.

Plan of Correction - To be completed: 09/14/2026

Resident R2's care plan was updated to reflect her change of orders regarding her code status. Resident R11's care plan was updated to reflect his change of orders regarding his fluid restrictions.
Education will be provided by the Director of Nursing/designee to Registered nurses and the Interdisciplinary Team regarding when to review and update care plans when revisions are made to resident orders or treatment needs.
The Director of Nurisng or designee will complete a 2-week look back on physician orders received to ensure care plans have been updated as needed.

Director of Nursing or designee will complete daily audits for 1 week on all new orders to ensure care plans have been updated, 2 x weekly audits for 2 weeks, then weekly for 2 weeks on residents receiving new orders to ensure care plans are updated as needed.

All audits will be reviewed by the Interdisciplinary Team during monthly Quality Assurance meetings.

483.25 REQUIREMENT Quality of Care:

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:

Based on clinical record reviews, as well as staff interviews, it was determined that the facility failed to follow physician's orders for one of 29 residents reviewed (Resident 1).

Findings include:

A quarterly Minimum Data Set (MDS) assessment for Resident 1, dated May 28, 2026, revealed that the resident was cognitively intact, was independent for most daily care needs, and had diagnoses that included anxiety and heart failure.

Physician's orders for Resident 1 dated May 23, 2026, included for the resident to be weighed daily and to contact the physician if the resident gained more than two pounds (lb) in 24 hours or more than five pounds in three days.

Review of weight records for Resident 1 dated July 2026 revealed that on July 13 the resident weighed 214.2 lb and on July 14 the resident weighed 216.4 lb indicating a 2.2 lb weight gain; on July 15 the resident weighed 215.8 lb and on July 16 the resident weighed 218 lb indicating a 2.2 lb weight gain; on July 23 the resident weighed 216.6 lb and on July 24 the resident weighed 219.4 lb indicating a 2.8 lb weight gain. There was no documented evidence that the physician was notified of the weight gain greater than two lb in 24 hours on the above-mentioned dates as ordered.

Physician's orders for Resident 1 dated June 29, 2026, included for the resident to have a consult with a psychiatry provider.

Nurse's note for Resident 1 dated June 29, 2026, at 4:40 p.m. included that the resident's wife had concerns that the resident was anxious all the time, the physician was notified, and that a consult for psychiatry due to anxiety was ordered. There was no documented evidence as of August 12, 2026, that the resident was seen by psychiatry as ordered.

Interview with the Director of Nursing on August 13, 2026, at 10:02 a.m. confirmed that the physician was not notified of Resident 1's weight gain on the above-mentioned dates and times and should have been, and that Resident 1 did not receive a psychiatry consult as ordered and should have.

28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Plan of Correction - To be completed: 09/14/2026

A psychiatry consultation was arranged and completed for Resident R1 on August 14,2026 and new orders received.
A review of Resident R1records indicated that resident had an order for daily weights and to notify the physician of weight gain over 2 pounds. There was no documented evidence of physician notification on 4 occasions throughout July. The physician was notified of changes in weight.
Education will be completed by Director of Nursing/designee to licensed nurses to review weight orders and Report weight gains or losses to physicians per orders. Nurses are to document notification and physician response in resident chart.

The Director of Nursing or designee will do a 2-week look back on resident weights noting any weight changes and physician notification. Any discrepancies will be provided to the Registered Dietician for further review.

Director of Nursing or designee will complete daily audit for 1 week on weights, 2 x weekly audits for 2 weeks, then weekly for 2 weeks on resident weights and if physician was notified for weight changes as ordered.

All audits will be reviewed by the Interdisciplinary Team during monthly Quality Assurance meetings.

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI:

§483.25(e) Incontinence.
§483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

§483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

§483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.

Observations:

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that a resident with a foley catheter received appropriate treatment and services to prevent urinary tract infections to the extent possible for one of 29 residents reviewed (Residents 11).

Findings include:

The facility's policy regarding urinary catheter (a tube inserted and held in the bladder to drain urine) care, dated July 28, 2026, indicated that the purpose of the procedure was to prevent urinary catheter associated complications, including urinary tract infection. Staff are to be sure that the catheter tubing and drainage bag are kept off of the floor.

An admission Minimum Data Set (MDS) assessment for Resident 11, dated May 15, 2026, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, had an indwelling urinary catheter, and had diagnoses that included Benign Prostatic Hyperplasia (BPH- condition in which the prostate gland [a walnut-sized gland in the male reproductive system that sits directly below the bladder] grows larger than normal).

Physician's orders for Resident 11, dated May 11, 2026, included an order for the resident to have a suprapubic catheter (a thin, flexible tube placed directly into your bladder through a small cut in your lower belly) connected to straight bag gravity drainage for urinary retention/severe BPH.

Observations on August 10, 2026, at 10:46 a.m. revealed that Resident 11 was in bed, and his catheter drainage bag was lying on the floor on the right side of the bed.

Interview with Nurse Aide 2 on August 10, 2026, at 10:50 a.m. confirmed that Resident 11's urinary drainage bag should not be lying on the floor.

Interview with the Nursing Home Administrator on August 10, 2026, at 11:27 a.m. confirmed that Resident 11's urinary catheter drainage bag should not have been lying on the floor.

28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Plan of Correction - To be completed: 09/14/2026

Resident R11's catheter bag was changed and a new privacy cover was placed over the drainage bag. Explanation was provided to the resident regarding the process for keeping the bag covered.
Education was presented by Director of Nursing/designee to staff to view catheter drainage bags during rounds assuring that drainage bags/urinary device tubing are not touching the floor and are kept in a privacy bag when applicable.

The Assistant Director of Nursing/designee will complete rounds including observations of urinary drainage bags/catheter tubing placement to ensure proper placement and privacy.
Assistant Director of Nursing/designee will complete rounds daily x one week, bi-weekly x 2 weeks, weekly x 2 weeks, monthly for 2 months. During these rounds, observations for proper catheter tubing and placement will be completed.
All audits will be reviewed by Interdisciplinary Team during monthly Quality Assurance meetings.

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