Pennsylvania Department of Health
ASPEN NURSING AND REHAB CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 54 surveys for this facility. Please select a date to view the survey results.

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

Initial comments:Name: - Component: -- - Tag: 0000

Based on an Emergency Preparedness Survey completed on August 12, 2026, it was determined that Aspen Nursing and Rehab Center had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(d), 416.54(d), 418.113(d), 441.184(d), 482.15(d), 483.475(d), 483.73(d), 484.102(d), 485.542(d), 485.625(d), 485.68(d), 485.727(d), 485.920(d), 486.360(d), 491.12(d), 494.62(d) STANDARD EP Training and Testing:

Least serious 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 has the potential for causing no more than a minor negative impact on the resident.

§403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d).

*[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years.

*[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually.

*[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i).

*[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years.

Observations:
Name: - Component: -- - Tag: 0036

Based on document review and interview, the facility failed to develop an emergency preparedness plan that included annual emergency preparedness plan training for all staff for one of one plan.

Findings include:

Document review on August 12, 2026, at 11:50 a.m., revealed the facility lacked annual staff emergency preparedness plan training within the previous twelve months.

Interview with the administrator on August 12, 2026, at 11:50 a.m., confirmed the facility lacked the training documentation.

Plan of Correction - To be completed: 09/15/2026

The Emergency Preparedness Plan for the facility is being revised and simplified as per recommendations. Upon completion all staff will be re-educated on the facility Emergency Preparedness Plan for the Aspen Nursing and Rehabilitation Center. Additionally, all new hires will complete a new hire orientation to include documented review of the Emergency Preparedness Plan and annually thereafter.

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID #021802
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on August 12, 2026, it was determined that Aspen Nursing and Rehab Center was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type V (000), unprotected, wood frame building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Hazardous Areas - Enclosure:

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.

Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0321

Based on observation and interview, the facility failed to maintain hazardous area enclosures in two of over five hazardous areas.

Findings include:

Observation on August 12, 2026, between 9:52 a.m. and 9:54 a.m., revealed the following deficiencies in the west terrace hallway:

A. (9:52 a.m.) Oxygen storage room self-closing door failed to positively latch in the frame;
B. (9:54 a.m.) Soiled linen room self-closing door failed to positively latch in the frame.

Interview with the maintenance supervisor on August 12, 2026, at 9:54 a.m., confirmed the doors failed to positively latch in their frames.

Plan of Correction - To be completed: 09/15/2026

The Oxygen Storage room door and Soiled Linen room door on the West terrace were sanded and reset to the door frame to ensure positive latching.
All other facility doors were assessed by the Maintenance Team to ensure positive closure and latching.
All staff were educated on alerting the Maintenance Team via a Maintenance slip if doors are noted to be sticking or not closing properly.
The Maintenance Director or designee will audit doors randomly with morning rounds to ensure proper closure. Audits will be completed and documented daily x5, weekly x2, then monthly x2 with results to the Quality Assurance Committee.

NFPA 101 STANDARD Cooking Facilities:

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.

Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324

Based on document review and interview, the facility failed to maintain cooking facilities in one of one main kitchen.

Findings include:

Document review on August 12, 2026, at 10:16 a.m., revealed the facility lacked documentation that the kitchen exhaust semi-annual hood cleaning had been conducted during the first half of the year.

Interview with the maintenance supervisor on August 12, 2026, at 10:16 a.m., confirmed the facility lacked the documentation at the time of the survey.

Plan of Correction - To be completed: 09/15/2026

United Safety was onsite on the night of 8/25/26 to complete semi-annual hood cleaning.
A hood cleaning schedule has been established with the outside vendor to ensure scheduling on a semi-annual basis and financial information for the new ownership has been provided.
Documentation of scheduled visits will be maintained in the electronic TELS system to ensure timely completion of required assessments and cleaning.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on document review and interview, the facility failed to remain in compliance with sprinkler system regulations for one of one system.

Findings include:

Document review on August 12, 2026, at 10:30 a.m., revealed the sprinkler gauges had not been replaced or calibrated within the previous five years.

Interview with the maintenance director on August 12, 2026, at 10:30 a.m., confirmed the five-year gauge replacement/calibration was not completed at the time of the survey.

Plan of Correction - To be completed: 09/15/2026

Clemmer Fire Safety will be on site for sprinkler testing and will be replacing the gauges and calibrating as needed.
Documentation of completion of 5 year gauge replacement and calibration will be maintained via the TELS system to ensure timely completion.

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