ASPEN LEAF ASSISTED LIVING-LIMON 6TH CO

An administrative relicensure survey was completed on 4/13/26. No deficiencies were cited. A change of ownership occurred on 10/21/25.

A revisit survey was completed on 4/26/24 for all previous deficiencies cited on 2/15/24. The facility is in compliance with all deficiencies that were cited.

A revisit survey was completed on 4/26/24 for all previous deficiencies cited on 2/15/24. The facility is in compliance with all deficiencies that were cited.

A licensure complaint prompted by #CO34780, was completed on 2/15/24. Deficiences were cited.

Based on record review and interview, the residence failed to complete a comprehensive assessment that included all required information, affecting two of three sample residents who had unique food and dining preferences or restrictions (#1, #3). Findings include: 1. Resident #1 was admitted to the residence on 1/23/23. An alternate menu read the meal choices were leftovers from a previous meal, a cheese sandwich, peanut butter and jelly sandwich and a choice side with all entrees of vegetable medley, soup du jour (chef's choice), or regularly scheduled meal sides. A progress note dated 4/10/23 read the resident had dental surgery. A progress note dated 4/11/23, read Resident #1 was in pain that all her teeth were taken out. The residence's most recent assessment for Resident #1, dated 10/24/23, read the resident had peanut allergies. Under "dietary preferences" Resident #1's care plan read there were no concerns. On 2/15/24 at 7:15 a.m., Staff #2 stated the owner took grilled cheese off the menu and replaced it with a cheese sandwich due to Resident #1's frequent requests for grilled cheese. Staff #2 stated she was one of the cooks at the residence and had no problem making grilled cheese as an alternate, and would still do so on occasion since she did not like telling Resident #1 "no." Staff #2 stated Resident #1 did not have orders for a modified diet; however, stated she did not have all her teeth and it was easier for her to eat soft foods, and had a strong preference for grilled cheese specifically. On 2/15/24 at 7:24 a.m., Staff #1 stated the last time Resident #1 asked for a grilled cheese sandwich was on 2/14/24, and stated she would frequently ask for grilled cheese when she did not like the meal that was served or had difficulty eating it. On 2/15/24 at 7:29 a.m., Resident #1 stated grilled cheese was one of her favorite foods and was easiest for her to eat out of the foods on the alternate menu, because the bread was flaky and did not stick to her mouth like the cheese sandwich or peanut butter and jelly sandwich did. Resident #1 stated it had been difficult to eat since she had her teeth removed in April 2023, and in the fall of 2023, the owner removed grilled cheese from the alternate menu and replaced it with a cheese sandwich. On 2/15/24 at 2:19 p.m., the administrator stated Resident #1 had dental work shortly after she moved in and had dental work done. Contrary to Staff #2's interview, the administrator stated Resident #1 would frequently request grilled cheese and it would overwhelm the cooks to make it last minute. The administrator further stated she was not aware assessments were required to include dietary preferences and restrictions. 2. There was similar deficient practice for Resident #3.

Based on observation, interviews and record review, the residence failed to implement a fall management which included detailing in each resident's care plan the individualized approach necessary to address fall risks related to deficits in strength and balance, affecting three of four sample residents who fell (#1 #2, #4) and one former resident (#6). Specifically, former Resident #6 had documented falls on 4/23, twice on 9/3, and 9/4. The residence failed to update former Resident #6's care plan to include individualized approaches necessary to address the resident's fall risk since 3/15/23. The fall on 4/23/23 resulted in no injury. Subsequently, former Resident #6 sustained a fall on 9/3/23 at 5:17 a.m., which resulted in a skin tear to the right hand and on 9/3/23 at 10:44 p.m., which resulted in skin tears to the resident's elbow and both hands. On 9/4/23 the resident sustained another fall without injury; however, on 9/5 and 9/6/23 the resident experienced rib and hip pain and required two person assistance with all transfers. The resident was transported to the hospital and found to have a fractured hip due to the fall on 9/3 or 9/4/24. Findings include:1. Residence policyThe residence's Fall Management policy, dated 10/2/21, read in part: "the (residence) has developed policies and procedures to establish a fall management program. The program includes ... detailing in each (resident's) care plan the individualized approach necessary to address fall risk related to deficits in strength, balance and eyesight."2. Former Resident #6 was admitted to the residence on 6/4/22 with a diagnosis of osteoarthritis. The residence's most recent assessment, which was the same as the residence's care plan for former Resident #6, dated 3/15/23, read the former resident required a cane and walker for mobility. The care plan further read the former resident was at risk for falls and staff were to monitor the resident at all times for signs or symptoms of weakness, encourage daily exercise groups to assist in strength building and endurance. The former resident required stand by assistance with transfers and ambulation. However, the care plan did not include that the resident required reminders to call for assistance with transfers, refused to wear shoes with traction or grip socks and utilized a wheelchair for days when feeling weak or ambulating longer distances. A progress note dated 4/23/23, read former Resident #6 slid to the floor when transferring from his recliner to his wheelchair, since the former resident was wearing non-slip socks. The former resident was found to have no injuries. A progress note dated 9/3/23 at 5:17 a.m., read former Resident #6 transferred by himself from the toilet to his wheelchair and slid onto the floor. The former resident sustained a skin tear on his right hand. A progress note dated 9/3/23 at 10:44 p.m., read former Resident #6 was found on the bathroom floor and ambulated independently without his walker. The former resident sustained skin tears on his elbow and both hands that were bleeding. The former resident refused to go to the hospital. Former Resident #6's legs were shaking and he was unable to move them, which required two staff members to stand him up. A progress note dated 9/4/23, read former Resident #6 was found on the floor and tried to transfer from his wheelchair to his recliner without staff assistance. The former resident was found to have no injuries. A progress note dated 9/5/23, read former Resident #6 required two person transfer assistance throughout the day and stated he could not move his legs. When the assistant administrator (AA) tried to transfer him, he was unable to stand upright, would bend at the waist and sit back down. Former Resident #6 removed his bandaged skin tears and his sheets and pillow cases had blood on them. A progress note dated 9/6/23, read former Resident #6 complained of hip and rib pain. It took two staff members to get the former resident dressed and to the bathroom. The former resident stated he felt he broke something in his ribs and thought the hip pain was from a previous break. The former resident agreed to go to the hospital and was sent out. Further, a "master" care plan dated 9/13/23, which was created when former Resident #6 was at the hospital, read the former resident required one person assistance with transfers, assistance and reminder to put socks and shoes on, utilized a walker and wheelchair, and required the removal of clutter to reduce fall risk. However, the former resident had not returned to the residence after he was sent out to the hospital on 9/6/23. Moreover, the fall interventions from the care plan dated 9/13/23, were not in place when the former resident still resided at the residence. On 2/15/24 at 8:10 a.m., the administrator stated former Resident #6 moved out of the residence after he was sent to the hospital after a fall in September 2023. The administrator stated the former resident sustained a fall, refused transport, and three days later complained of pain in his leg and was unable to stand. The administrator stated they were made aware by the resident's family member that he had fractured his hip. On 2/15/24 at 10:07 a.m., former Resident #6's family member stated that former Resident #6 had sustained a hip fracture from one of his falls either on 9/3 or 9/4/23. Former Resident #6's family member stated other than a wheelchair and walker, he was unaware of any interventions the residence had put in place. The family member further stated the resident used a wheelchair after the fall of 2022 when the former resident sustained a fall and broke his hip the first time. The family member further stated after Resident #6's fall on 9/4/23 and hospitalization, he had moved the resident out of the residence. On 2/15/24 at 11:44 a.m., the AA stated former Resident #6 required reminders to use his call pendant for assistance and to wear shoes since most of his falls were due to him wearing non-grip socks. The AA further stated the former resident required one person assistance with transfers, which changed to two person assistance during the last week the resident resided at the residence, due to increased weakness and hip pain. The AA stated former Resident #6 used a walker for ambulation in his room, and required a wheelchair to ambulate around the residence or on days when the resident felt weak in his room. On 2/15/24 at 12:57 p.m., the administrator stated that assessments were what the residence used as care plans. The administrator stated the master care plan created 9/13/23 for former Resident #6 was unable to be updated due to their electronic health system, and stated updates were made through corresponding assessments. The administrator stated she was responsible for updating the assessments/care plan and should be updated whenever a resident has repeated falls or is hospitalized. The administrator stated she was unaware care plans needed to be updated between falls to include individualized interventions to reflect the former residents' fall risk and ambulation needs. On 2/15/24 at 1:00 p.m, the administrator stated former Resident #6 refused to notify staff for transfer assistance and believed that was the cause of most of his falls since he required one person assistance. The administrator acknowledged she had not updated the care plan until after the former resident was hospitalized on 9/6/23. 3. Resident #2 was admitted to the residence on 1/11/22 with diagnoses that included osteoarthritis and osteoporosis. The residence's most recent assessment, which was also the same as the residence's care plan, dated 10/24/23, read Resident #2 was a fall risk and required a walker for ambulation, required monitoring and safety with oxygen equipment and monitoring for increased weakness in legs with physical therapy. The care plan further read staff were to monitor at all times for signs or symptoms of weakness, encourage daily exercise groups to assist in strength building and endurance, and required stand by assistance with transfers and ambulation. An incident report dated 12/2/23, read Resident #2 sustained a fall ambulating independently in her bedroom, and was found on the floor and stated her lower back hurt. There were no injuries. A progress note dated 12/17/23, read Resident #2 was found on the floor and stated her legs got tangled in her oxygen tubing. There were no injuries. A progress note dated 1/2/24, read Resident #2 was found on the floor naked and the resident stated she slipped while trying to take a shower independently. Resident #2 did not have her walker with her or her call pendant. The resident was found to have no injuries. An incident report dated 1/29/24, read Resident #2 went to get coffee in the dining area and fell down. Resident #2 stated she felt her legs get weak; however had no pain from her fall. On 2/15/24 at 11:00 a.m., Resident #2 was observed sleeping in her recliner, with her walker next to her chair. On 2/15/24 at 11:44 a.m., the AA stated Resident #2 fell due to not calling for assistance with transfer and in the shower. The AA stated Resident #2 utilized a walker for ambulation. On 2/15/24 at 12:57 p.m., the administrator stated that assessments were what the residence used as care plans. The administrator stated she was responsible for updating the assessments/care plan and should be updated whenever a resident has repeated falls or is hospitalized. The administrator stated she was unaware care plans needed to be updated between falls to include individualized interventions to reflect Resident #2's fall risk and ambulation needs. The administrator further stated incident reports were the same as progress notes and staff were required to complete either after an out of the ordinary event occurred. On 2/15/24 at 1:00 p.m, the administrator stated Resident #2 would fall due to getting tangled in her oxygen tubing and due to not calling for assistance with transfers. 4. There was similar deficient practice for Residents #1 and #4.

A certification complaint prompted by #CO34781, was completed on 2/15/24. A deficiency was cited.

Based on interview and record review, the facility (residence) failed to document in the assessment that the residence was able to support a resident's needs, affecting two of four sample residents (#1, #3). Findings include: 1. Resident #1 was admitted to the residence on 1/23/23. An alternate menu read the meal choices were leftovers from a previous meal, a cheese sandwich, peanut butter and jelly sandwich and a choice side with all entrees of vegetable medley, soup du jour (chef's choice), or regularly scheduled meal sides. A progress note dated 4/10/23 read the resident had dental surgery. A progress note dated 4/11/23, read Resident #1 was in pain that all her teeth were taken out. The residence's most recent assessment for Resident #1, dated 10/24/23, read the resident had peanut allergies. Under "dietary preferences" Resident #1's care plan read there were no concerns. On 2/15/24 at 7:15 a.m., Staff #2 stated the owner took grilled cheese off the menu and replaced it with a cheese sandwich due to Resident #1's frequent requests for grilled cheese. Staff #2 stated she was one of the cooks at the residence and had no problem making grilled cheese as an alternate, and would still do so on occasion since she did not like telling Resident #1 "no." Staff #2 stated Resident #1 did not have orders for a modified diet; however, stated she did not have all her teeth and it was easier for her to eat soft foods, and had a strong preference for grilled cheese specifically. On 2/15/24 at 7:24 a.m., Staff #1 stated the last time Resident #1 asked for a grilled cheese sandwich was on 2/14/24, and stated she would frequently ask for grilled cheese when she did not like the meal that was served or had difficulty eating it. On 2/15/24 at 7:29 a.m., Resident #1 stated grilled cheese was one of her favorite foods and was easiest for her to eat out of the foods on the alternate menu, because the bread was flaky and did not stick to her mouth like the cheese sandwich or peanut butter and jelly sandwich did. Resident #1 stated it had been difficult to eat since she had her teeth removed in April 2023, and in the fall of 2023, the owner removed grilled cheese from the alternate menu and replaced it with a cheese sandwich. On 2/15/24 at 2:19 p.m., the administrator stated Resident #1 had dental work shortly after she moved in and had dental work done. Contrary to Staff #2's interview, the administrator stated Resident #1 would frequently request grilled cheese and it would overwhelm the cooks to make it last minute. The administrator further stated she was not aware assessments were required to include dietary preferences and restrictions. 2. There was similar deficient practice for Resident #3.

A recertification survey was completed on 11/29/23. No deficiencies were cited.

A relicensure survey was completed on 11/29/23. No deficiencies were cited.

A revisit survey was completed on 5/4/23 for all previous deficiencies cited on 5/25/22. No deficiencies were cited.

A revisit survey was completed on 5/4/23 for all previous deficiencies cited on 5/25/22. No deficiencies were cited.