Aspen Meadows Rehab: No Lift Safety Policy Found - MT
The inspection, conducted on September 10, 2025, was a complaint survey. What it found was a gap that sits at the center of one of the most physically dangerous tasks in any nursing home: moving a resident who cannot move themselves.
The piece of equipment at issue is a Hoyer lift, a mechanical sling system used throughout long-term care to transfer residents in and out of beds, wheelchairs, and toilets. Used correctly, a Hoyer lift protects both the resident and the staff member. Used incorrectly, or used without clear guidance on how many people must be present, it can drop a resident or injure a worker.
The inspector requested the facility's lift use policy on September 8, at 3:52 in the afternoon. The staff member identified in the report, referred to as Staff Member A, said she thought it would take two people to operate the lift. She said she would look for a policy.
She couldn't find one.
By the morning of September 10, Staff Member A told the inspector she had reviewed the manuals and still couldn't locate anything specifying how many people the lift required. "I cannot find a policy on lifts," she said, "and have reviewed the manuals and cannot find where it says how many people it should take to use them."
She had, at some point, watched a manufacturer's video about the lift. In that video, one person was shown operating the Hoyer alone.
That detail matters. Staff Member A said she would still require two staff members to use the Hoyer lifts, because she felt it was safest. That instinct may be sound. But it wasn't written down anywhere. It wasn't a policy. It was a personal conviction held by one staff member, unenforceable and invisible to anyone who hadn't heard her say it out loud.
By the time the survey closed, no lift use policy had been received from the facility.
The violation was cited under F0725, which covers the requirement that a facility maintain sufficient staff with the competencies and skill sets necessary to carry out the functions of the job. Inspectors rated the level of harm as minimal harm or potential for actual harm, and noted that some residents were affected.
That rating sits at the lower end of the federal harm scale. But the absence of a written policy on lift use is not a paperwork problem. Nursing homes rely on Hoyer lifts and similar equipment daily, often multiple times a day, for residents who are entirely dependent on staff to move them. A resident in a sling, suspended off the ground, has no ability to correct what happens next. The question of whether one person or two people is operating that lift is not academic.
What the inspection report captures is something more common in nursing home oversight than dramatic single incidents: a foundational procedure that nobody wrote down, and that nobody could produce when asked. The manufacturer showed one person in a video. The staff member believed two was safer. Neither answer was the facility's official answer, because the facility had no official answer.
Staff Member A's response to the inspector had a quality of genuine searching to it. She looked. She reviewed the manuals. She watched the video. She came back and said she still couldn't find it. She said she would keep requiring two people anyway.
Whether anyone else at Aspen Meadows shared that standard, or knew it existed, the inspection report does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aspen Meadows Health and Rehabilitation Center from 2025-09-10 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 2026 · Our methodology
ASPEN MEADOWS HEALTH AND REHABILITATION CENTER in BILLINGS, MT was cited for violations during a health inspection on September 10, 2025.
The inspection, conducted on September 10, 2025, was a complaint survey.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.