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

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
ASPEN NURSING AND REHAB CENTER
Inspection Results For:

There are  131 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
ASPEN NURSING AND REHAB CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a revisit survey completed on May 18, 2026it was determined that MULBERRY HEALTHCARE AND REHABILITATION 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:


§ 211.12(f.1)(3) LICENSURE Nursing services. :State only Deficiency.
(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Based on review of nursing schedules and staffing information furnished by the facility, as well as staff interviews, it was determined that the facility failed to ensure a minimum of one nurse aide per 10 residents on the day shift for 13 of 17 days reviewed, failed to ensure a minimum of one nurse aide per 11 residents on the evening shift for 11 of 17 days reviewed, and failed to ensure a minimum of one nurse aide per 15 residents on the night shift for 16 of 17 days (24-hour periods) reviewed.

Findings include:

Nursing time schedules provided by the facility for the weeks of April 20, 2026, to May 6, 2026, review of facility census data indicated that on April 20, 2026, review of the facility census data indicated that the facility census was 53 for the day shift, which required 5.30 nurse aides during the day shift to provide care. Review of the nursing time schedules revealed 3.93 nurse aides provided care during the day shift. On April 20, 2026, review of the facility census data indicated that the facility census was 53 for the evening shift, which required 4.82 nurse aides to provide care. Review of the nursing time schedules revealed 4.67 nurse aides provided care during the evening shift. On April 20, 2026, review of the facility census data indicated that the facility census was 53 for the night shift, which required 3.53 nurse aides to provide care. Review of the nursing time schedules revealed 2.00 nurse aides provided care during the night shift.

On April 21, 2026, review of the facility census data indicated that the facility census was 54 for the day shift, which required 5.40 nurse aides during the day shift to provide care. Review of the nursing time schedules revealed 4.67 nurse aides provided care during the day shift. On April 21, 2026, review of the facility census data indicated that the facility census was 54 for the night shift, which required 3.60 nurse aides to provide care. Review of the nursing time schedules revealed 2.13 nurse aides provided care during the night shift.

April 22, 2026, review of the facility census data indicated that the facility census was 54 for the day shift, which required 5.40 nurse aides during the day shift to provide care. Review of the nursing time schedules revealed 4.30 nurse aides provided care during the day shift. On April 22, 2026, review of the facility census data indicated that the facility census was 54 for the evening shift, which required 4.91 nurse aides to provide care. Review of the nursing time schedules revealed 3.07 nurse aides provided care during the evening shift. On April 22, 2026, review of the facility census data indicated that the facility census was 54 for the night shift, which required 3.60 nurse aides to provide care. Review of the nursing time schedules revealed 2.27 nurse aides provided care during the night.

April 23, 2026, review of the facility census data indicated that the facility census was 55 for the evening shift, which required 5.00 nurse aides to provide care. Review of the nursing time schedules revealed 4.07 nurse aides provided care during the evening shift. On April 23, 2026, review of the facility census data indicated that the facility census was 55 for the night shift, which required 3.67 nurse aides to provide care. Review of the nursing time schedules revealed 2.13 nurse aides provided care during the night.

April 24, 2026, review of the facility census data indicated that the facility census was 55 for the day shift, which required 5.50 nurse aides during the day shift to provide care. Review of the nursing time schedules revealed 4.27 nurse aides provided care during the day shift. On April 24, 2026, review of the facility census data indicated that the facility census was 55 for the evening shift, which required 5.00 nurse aides to provide care. Review of the nursing time schedules revealed 4.57 nurse aides provided care during the evening shift. On April 24, 2026, review of the facility census data indicated that the facility census was 55 for the night shift, which required 3.67 nurse aides to provide care. Review of the nursing time schedules revealed 1.53 nurse aides provided care during the night.

April 25, 2026, review of the facility census data indicated that the facility census was 55 for the day shift, which required 5.50 nurse aides during the day shift to provide care. Review of the nursing time schedules revealed 4.83 nurse aides provided care during the day shift. On April 25, 2026, review of the facility census data indicated that the facility census was 55 for the night shift, which required 3.67 nurse aides to provide care. Review of the nursing time schedules revealed 2.03 nurse aides provided care during the night.

April 26, 2026, review of the facility census data indicated that the facility census was 55 for the day shift, which required 5.40 nurse aides during the day shift to provide care. Review of the nursing time schedules revealed 4.30 nurse aides provided care during the day shift.

April 27, 2026, review of the facility census data indicated that the facility census was 55 for the day shift, which required 5.50 nurse aides during the day shift to provide care. Review of the nursing time schedules revealed 3.93 nurse aides provided care during the day shift. On April 27, 2026, review of the facility census data indicated that the facility census was 55 for the evening shift, which required 5.00 nurse aides to provide care. Review of the nursing time schedules revealed 3.77 nurse aides provided care during the evening shift. On April 27, 2026, review of the facility census data indicated that the facility census was 55 for the night shift, which required 3.67 nurse aides to provide care. Review of the nursing time schedules revealed 2.13 nurse aides provided care during the night.

April 28, 2026, review of the facility census data indicated that the facility census was 56 for the day shift, which required 5.60 nurse aides during the day shift to provide care. Review of the nursing time schedules revealed 4.80 nurse aides provided care during the day shift. On April 28, 2026, review of the facility census data indicated that the facility census was 56 for the night shift, which required 3.73 nurse aides to provide care. Review of the nursing time schedules revealed 2.17 nurse aides provided care during the night.

April 29, 2026, review of the facility census data indicated that the facility census was 56 for the day shift, which required 5.60 nurse aides during the day shift to provide care. Review of the nursing time schedules revealed 5.27 nurse aides provided care during the day shift. On April 29, 2026, review of the facility census data indicated that the facility census was 56 for the evening shift, which required 5.09 nurse aides to provide care. Review of the nursing time schedules revealed 4.60 nurse aides provided care during the evening shift. On April 29, 2026, review of the facility census data indicated that the facility census was 56 for the night shift, which required 3.73 nurse aides to provide care. Review of the nursing time schedules revealed 2.07 nurse aides provided care during the night.

April 30, 2026, review of the facility census data indicated that the facility census was 55 for the day shift, which required 5.50 nurse aides during the day shift to provide care. Review of the nursing time schedules revealed 5.43 nurse aides provided care during the day shift. On April 30, 2026, review of the facility census data indicated that the facility census was 55 for the evening shift, which required 5.00 nurse aides to provide care. Review of the nursing time schedules revealed 4.07 nurse aides provided care during the evening shift. On April 27, 2026, review of the facility census data indicated that the facility census was 55 for the night shift, which required 3.67 nurse aides to provide care. Review of the nursing time schedules revealed 1.90 nurse aides provided care during the night.

May 1, 2026, review of the facility census data indicated that the facility census was 55 for the evening shift, which required 5.00 nurse aides to provide care. Review of the nursing time schedules revealed 4.67 nurse aides provided care during the evening shift. On May 1, 2026, review of the facility census data indicated that the facility census was 55 for the night shift, which required 3.67 nurse aides to provide care. Review of the nursing time schedules revealed 3.10 nurse aides provided care during the night.

May 2, 2026, review of the facility census data indicated that the facility census was 55 for the day shift, which required 5.50 nurse aides during the day shift to provide care. Review of the nursing time schedules revealed 5.23 nurse aides provided care during the day shift. On May 2, 2026, review of the facility census data indicated that the facility census was 55 for the night shift, which required 3.67 nurse aides to provide care. Review of the nursing time schedules revealed 3.00 nurse aides provided care during the night.

May 3, 2026, review of the facility census data indicated that the facility census was 54 for the day shift, which required 5.40 nurse aides during the day shift to provide care. Review of the nursing time schedules revealed 4.07 nurse aides provided care during the day shift. On May 3, 2026, review of the facility census data indicated that the facility census was 54 for the night shift, which required 3.60 nurse aides to provide care. Review of the nursing time schedules revealed 2.17 nurse aides provided care during the night.

May 4, 2026, review of the facility census data indicated that the facility census was 54 for the evening shift, which required 4.92 nurse aides to provide care. Review of the nursing time schedules revealed 3.63 nurse aides provided care during the evening shift. On May 4, 2026, review of the facility census data indicated that the facility census was 54 for the night shift, which required 3.60 nurse aides to provide care. Review of the nursing time schedules revealed 2.40 nurse aides provided care during the night.

May 5, 2026, review of the facility census data indicated that the facility census was 55 for the evening shift, which required 5.00 nurse aides to provide care. Review of the nursing time schedules revealed 4.77 nurse aides provided care during the evening shift. On May 4, 2026, review of the facility census data indicated that the facility census was 55 for the night shift, which required 3.67 nurse aides to provide care. Review of the nursing time schedules revealed 2.17 nurse aides provided care during the night.

May 6, 2026, review of the facility census data indicated that the facility census was 54 for the day shift, which required 5.40 nurse aides during the day shift to provide care. Review of the nursing time schedules revealed 4.27 nurse aides provided care during the day shift. On May 6, 2026, review of the facility census data indicated that the facility census was 54 for the evening shift, which required 4.91 nurse aides to provide care. Review of the nursing time schedules revealed 4.10 nurse aides provided care during the evening shift. On May 6, 2026, review of the facility census data indicated that the facility census was 54 for the night shift, which required 3.60 nurse aides to provide care. Review of the nursing time schedules revealed 3.07 nurse aides provided care during the night.

No additional excess higher-level staff were available to compensate for this deficiency for the dates listed above.

Interview with the Nursing Home Administrator on May 8, 2026, at 2:42 p.m. confirmed that the facility did not meet the required nurse aide-to-resident staffing ratios for the days listed above.





 Plan of Correction - To be completed: 08/05/2026

The facility attempts to staff to meet state required number of staff hours and ratios for nursing assistants per current state regulations. The facility offers shift bonus for pick up shifts and for additional hours in case of call offs. Registered nurses, Licensed practical nurses, and nursing administration all assist to help fill in as needed. An active recruitment campaign is ongoing which includes sign on bonuses, shift differentials, and employee referral bonuses. Agency staff are contracted as available to fill in needed shifts. The Nursing Home Administrator and Director of Nursing meet daily to review staffing sheets to ensure proper staffing. Time and attendance is reviewed daily for ratios and staffing numbers. These calculations are recorded daily in labor tracking and submitted to the facility's management company ongoing. The facility has experienced a high volume of call offs recently and has offered an attendance bonus in addition to the other bonuses listed above.
Monthly tracking of labor hours will be reported at the monthly Quality Assurance meetings.

§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:

Based on review of nursing schedules for April 20 through May 6, 2026, the staffing information furnished by the facility, as well as staff interviews, it was determined that the facility failed to ensure a minimum of one LPN per 25 residents on the day shift on three of 17 days, one LPN per 30 residents on the evening shift on three of 17 days; and one LPN per 40 residents on the night shift on four of 17 days (24-hour periods) reviewed.

Findings Include:

Nursing time schedules provided by the facility for the weeks of April 20 through May 6, 2026, revealed that on April 21, 2026, the facility census was 54 during the day shift, which required 2.16 LPNs to provide care. Review of the nursing time schedules revealed that 1.60 LPNs provided care on the day shift. On April 21, 2026, the facility census was 54 during the evening shift, which required 1.80 LPNs to provide care. Review of the nursing time schedules revealed 1.73 LPNs provided care during the evening shift.

On April 25, 2026, the facility census was 55 during the night shift, which required 1.38 LPNs to provide care. Review of the nursing time schedules revealed that 1.10 LPN's provided care during the night shift.

On April 26, 2026, the facility census was 55 during the day shift, which required 2.20 LPN's to provide care. Review of the nursing time schedules revealed that 1.93 LPN's provided care during the day shift. On April 26, 2026, the facility census was 55 during the night shift, which required 1.38 LPNs to provide care. Review of the nursing time schedules revealed that 1.10 LPNs provided care during the night shift.

On April 29, 2026, the facility census was 56 during the night shift, which required 1.40 LPNs to provide care. Review of the nursing time schedules revealed that 1.10 LPN's provided care during the night shift.

On May 1, 2026, the facility census was 55 during the evening shift, which required 1.83 LPNs to provide care. Review of the nursing time schedules revealed that 1.57 LPN's provided care during the evening shift.

On May 2, 2026, the facility census was 55 during the day shift, which required 2.20 LPN's to provide care. Review of the nursing time schedules revealed that 2.10 LPN's provided care during the day shift. On May 2, 2026, the facility census was 55 during the night shift, which required 1.38 LPNs to provide care. Review of the nursing time schedules revealed that 1.07 LPNs provided care during the night shift.

On May 3, 2026, the facility census was 54 during the evening shift, which required 1.80 LPNs to provide care. Review of the nursing time schedules revealed that 1.47 LPN's provided care during the evening shift.

No additional excess higher-level staff were available to compensate for this deficiency for the dates listed above.

Interview with the Nursing Home Administrator on May 8, 2026, at 2:42 p.m. confirmed that the facility did not meet the required LPN-to-resident staffing ratios for the dates listed above.





 Plan of Correction - To be completed: 08/05/2026

The facility attempts to staff to meet state required number of staff hours and ratios for licensed practical nurses per current state regulations. The facility offers shift bonus for pick up shifts and for additional hours in case of call offs. Registered nurses, Licensed practical nurses, and nursing administration all assist to help fill in as needed. An active recruitment campaign is ongoing which includes sign on bonuses, shift differentials, and an increased employee referral bonuses. Agency staff are contracted as available to fill in needed shifts. We also currently have 1 full time contract nurse. The Nursing Home Administrator and Director of Nursing meet daily to review staffing sheets to ensure proper staffing. Time and attendance is reviewed daily for ratios and staffing numbers. These calculations are recorded daily in labor tracking and submitted to the facility's management company ongoing.
Monthly labor tracking will be reported at the monthly quality assurance meetings.


§ 211.12(i)(2) LICENSURE Nursing services.:State only Deficiency.
(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:

Based on review of nursing schedules and staff interviews, it was determined that the facility failed to provide 3.20 hours of direct resident care for each resident for 17 of 17 days (24-hour periods) reviewed.

Findings include:

Nursing time schedules provided by the facility for the weeks of April 20 through May 6, 2026, revealed that the facility provided only 2.85 hours of direct care for each resident on April 20, 2026; 2.88 hours of direct care for each resident on April 21, 2026; 3.14 hours of direct care on April 22, 2026; 3.10 hours of direct care on April 23, 2026; 2.66 hours of direct care on April 24, 2026; 3.04 hours of direct care on April 25, 2026; 3.05 hours of direct care on April 26, 2026; 2.97 hours of direct care on April 27, 2026; 3.13 hours of direct care on April 28, 2026; 2,87 hours of direct care on April 29, 2026; 3.11 hours of direct care on April 30, 2026; 3.11 hours of direct care on May 1, 2026; 3.05 hours of direct care on May 2, 2026; 3.10 hours of direct care on May 3, 2026; 3.10 hours of direct care on May 4, 2026; 3.10 hours of direct care on May 4, 2026; 3.17 hours of direct care on May 5, 2026; 2.88 hours of direct care on May 6, 2026.

Interview with the Nursing Home Administrator on May 8, 2026, at 2:42 p.m. confirmed that the facility did not meet the required daily hours of direct resident care for each resident on the days listed above.





 Plan of Correction - To be completed: 08/05/2026

The facility attempts to staff to meet state required number of staff hours and ratios per current state regulations. The facility offers shift bonus for pick up shifts and for additional hours in case of call offs. Registered nurses, Licensed practical nurses, and nursing administration all assist to help fill in as needed. An active recruitment campaign is ongoing which includes an increased sign on bonus, shift differentials, and employee referral bonuses. An excessive number of call offs have been noted in recent months and an attendance reward system has been added. Agency staff are contracted as available to fill in needed shifts. The Nursing Home Administrator and Director of Nursing meet daily to review staffing sheets to ensure proper staffing. Time and attendance is reviewed daily for ratios and staffing numbers. These calculations are recorded daily in labor tracking and submitted to the facility's management company ongoing. Monthly tracking of labor will be reported at the monthly quality assurance meetings.

Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance


Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement
Visit the PA Power Port